RU2830358C2 - Method of skin-preserving mastectomy with reconstruction of de-epidermised fatty skin flap and free transplantation of nipple-areola complex in ptosis mammary glands - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention refers to medicine, namely to oncology and mammary gland surgery (MG) in cancer, implying removal of MG tissue and simultaneous reconstruction. Skin is incised according to Wise marking, nipple-areola complex and MG tissue are removed, de-epidermisation of the skin-subcutaneous flap of the mammary gland is performed in the area of the lower and upper slope, in the area of the removed mammary gland a de-epidermal skin-subcutaneous flap is placed as a sandwich, wherein the blood supply of the flap is preliminary examined using the intravenous administration of indocyanine, then the flap is fixed with interrupted sutures to the greater pectoral muscle on the border of the upper quadrants, a drainage is installed in the area of the formed mammary gland, free nipple-areola complex is fixed with interrupted sutures in the area of central quadrants of mammary gland to gland skin at level of 20 cm from clavicle, skin is closed in area of mammary gland.

EFFECT: use of the proposed method in clinical practice enables: preserving a greater pectoral muscle and preserving a functional component of the muscle; to perform single-stage breast reconstruction: removing a large amount of tissue with subsequent replacement with a de-epidermised fatty skin flap without using an endoprosthesis or muscle flaps; reduce the number of postoperative complications due to the use of intravenous administration of indocyanine, and in the presence of ischemic zones in the de-epidermis dermal-subcutaneous flap, the ischemic zones are intraoperatively dissected, and as a result, the percentage of necrosis in the postoperative period is reduced.

1 cl, 15 dwg

Description

The invention relates to medicine, namely to oncology and breast surgery for cancer, which involves the removal of breast tissue and one-stage reconstruction.

Subcutaneous mastectomy involves the removal of all breast tissue with the tumor node, while preserving the submammary fold and the nipple-areolar complex; when the nipple-areolar complex is removed, this intervention is referred to as skin-sparing mastectomy.

To restore the lost volume of mammary gland, autologous tissues (latissimus dorsi, rectus abdominis) or allomaterials (implants, expanders) are used, and a combination of allomaterials and flaps is also possible (combined reconstruction).

In case of removal of the nipple-areolar complex, various methods of its restoration are used, for example, with one’s own tissues, allomaterials, and tattooing.

The use of a de-epidermized autodermal flap with preservation of the nipple-areolar complex, which serves as a pocket for an endoprosthesis when performing subcutaneous mastectomy for cancer, is known (Sobolevsky V.A., Kuliev A.T., Krokhina O.V. Experience in using a de-epidermized autodermal flap in one-stage breast reconstruction with an endoprosthesis. Plastic surgery and aesthetic medicine. 2021; (1): 5–12).

The closest (prototype) is the method of implant stabilization in reconstructive plastic surgery in patients with breast cancer (RU 2811656 C1, 2024). The skin around the mammary gland is dissected with bordering incisions extended to the posterior axillary line, and the zone within the anterior and posterior axillary region is de-epidermized along the preoperative marking lines. Then, a skin-sparing mastectomy is performed and a silicone implant is installed in the projection of the removed mammary gland. The de-epidermized zone is cut out and transferred to the lateral edge of the implant, the skin cover is sutured over the implant, after dissection with bordering incisions and de-epidermization of the skin along the preoperative marking lines from the anterior to the posterior axillary region, the tissues of the de-epidermized zone are cut off along the medial, lateral and superior edges. Next, a de-epidermized dermal-fat flap is formed by dissection in the fat layer while preserving the subdermal vascular blood supply. The formed flap is moved upward along the edge of the lateral border of the installed implant, while the length of the flap corresponds to the length of the lateral edge of the installed implant, and the width of the flap corresponds to its length for adequate blood supply. Next, the dermal-fat flap is fixed with absorbable sutures to the subcutaneous fat layer of the upper edge of the bordering incision, then the skin cover is sutured along the entire length of the incision above the installed implant and above the de-epidermized dermal-fat flap. The method involves the use of a de-epidermized skin flap of the mammary gland to strengthen the implant after subcutaneous mastectomy.

However, in the known method, de-epidermization of the cutaneous-subcutaneous flap of the lower slope is performed, and we propose de-epidermization of the cutaneous-subcutaneous flap of the upper slope, while the de-epidermized cutaneous-subcutaneous flaps are used to replace the removed tissues of the mammary gland.

All known methods involve the placement of an implant in a de-epidermized skin-fat flap and differ only in the fixation of the flap in relation to the gland.

The authors of the invention consider performing skin-preserving mastectomy in breast cancer, where the reconstruction of the removed mammary gland is performed with a de-epidermized skin-fat flap, thus, we do not use allomaterials and autotissues brought from outside.

The technical result is a one-stage reconstruction of the mammary gland with the removal of all tissue followed by replacement with a de-epidermized skin-fat flap while preserving the pectoralis major muscle and eliminating the use of an implant.

The technical result is achieved due to the fact that, just as in the known method (prototype), de-epidermization of the skin-subcutaneous flap and replacement of the removed breast tissue are performed.

The peculiarity of the claimed method is that an incision of the skin is made according to the Wise marking, the nipple-areolar complex and the breast tissue are removed, deepidermization of the cutaneous-subcutaneous flap of the breast is performed in the area of the lower and upper slopes, a sandwich-type de-epidermized cutaneous-subcutaneous flap is placed in the area of the removed breast, and the blood supply to the flap is preliminarily examined using intravenous administration of indocyanine, then the flap is fixed with interrupted sutures to the pectoralis major muscle at the border of the upper quadrants, drainage is installed in the area of the formed breast, the free nipple-areolar complex is fixed with interrupted sutures in the central part of the breast to the skin at a level of 20 cm from the clavicle, as shown in Fig. 13, the skin of the breast is sutured.

The invention is explained by a detailed description, a clinical example and illustrations, which depict:

Fig. 1 - photo illustration of patient K.: a) right lateral projection, b) front view, c) left lateral projection.

Fig. 2 - photo illustration of patient K. during surgery: skin incision according to Wise markings.

Fig. 3 - photo illustration of patient K. during surgery: excision of the nipple-areolar complex.

Fig. 4 - photo illustration of patient K. during surgery: removed mammary gland, preserved skin-fat flap.

Fig. 5 - photo illustration of patient K. during surgery: removed breast tissue.

Fig. 6 - photo illustration of patient K. during surgery: de-epidermization of the skin of the mammary gland.

Fig. 7 - photo illustration of patient K. during surgery: removed skin of the mammary gland.

Fig. 8 - photo illustration of patient K. during surgery: de-epidermized skin-fat flap, defect in the center (area of the nipple-areolar complex).

Fig. 9 – photo illustration of folding of the cutaneous-subcutaneous flap in the form of a sandwich: a) beginning of folding of the flap; b) final appearance.

Fig.10 - Striker screen (assessment of flap blood supply).

Fig. 11 - photo illustration of patient K. during surgery: suturing with interrupted sutures of a cutaneous-subcutaneous flap in the area of the upper quadrants of the mammary gland.

Fig. 12 - view on the operating table: preliminary sutures on the mammary glands.

Fig. 13 - photo illustration of patient K. during surgery: marking of skin sutures for fixation of the free nipple-areolar complex.

Fig. 14 - photo illustration of patient K. during surgery: skin sutures in the nipple-areolar complex area.

Fig. 15 - External appearance of patient K., 7 days after surgery: a) right lateral projection, b) front view, c) left lateral projection.

The method is carried out as follows.

A patient with grade III breast ptosis undergoes a bilateral skin-sparing mastectomy.

A skin incision is made along the Wise markings on the mammary gland (Fig. 2), deepidermization of the cutaneous-subcutaneous flap of the mammary gland is performed in the area of the lower and upper slopes (Figs. 4, 7), with the removal of the nipple-areolar complex (Fig. 3), the mammary gland tissue is removed (Figs. 5, 6) and the de-epidermized cutaneous-subcutaneous flap is used to reconstruct the gland volume, which is folded and placed in the area of the removed mammary gland like a sandwich (Figs. 8, 9, 11). The de-epidermized cutaneous-subcutaneous flap is fixed with interrupted sutures to the pectoralis major muscle at the border of the upper quadrants (Fig. 12), while the blood supply to the flap is preliminarily examined using intravenous administration of indocyanine (Fig. 10). A drainage is installed in the area of the formed mammary gland, the free nipple-areolar complex is fixed to the skin of the gland with interrupted sutures in the area of the central quadrants of the mammary gland at a level of 20 cm from the clavicle (Fig. 14, 15), the skin in the area of the mammary gland is sutured (Fig. 13).

Clinical example

Patient K., 39 years old, was hospitalized in the Department of Oncology and Reconstructive Plastic Surgery of the Breast and Skin of the P.A. Herzen Moscow Oncology Research Institute with the diagnosis: Right breast cancer, stage IIA pT1N1M0G3. Luminal type B, Her2 negative. Condition after combination treatment in 2023-2024. In the process of hormone therapy. Carrier of a mutation in the BRCA2 gene (Fig. 1 a, b, c).

A patient with a nodular formation in the right mammary gland underwent sectoral resection of the right mammary gland at the Hadassah Clinic on September 7, 2023. Histologically: invasive carcinoma. For further examination and treatment, she contacted the P.A. Herzen Moscow Oncology Research Institute.

On October 9, 2023, a mutation in the BRCA2 gene was detected using the NGS method.

According to the examination data, a metastasis was diagnosed in the right axillary lymph node; cytological examination of the puncture of the right axillary lymph node showed a metastasis of cancer.

On October 23, 2023, axillary-subscapular lymphadenectomy was performed on the right.

During a routine histological examination, 1 out of 10 axillary lymph nodes showed metastasis of cancer without signs of specificity.

Discussed at the oncology council on 22.11.2023: at the second stage of complex treatment, APCT according to the 4TC scheme was recommended. The full course of APCT was implemented in the Chemotherapy Department of the P.A. Herzen Moscow Oncology Research Institute from 28.11.2023 to 05.02.2024.

It was planned to perform radiation therapy on the resected right mammary gland, but taking into account the data of the BRCA2 mutation and the burdened family history, surgical treatment is planned in the amount of bilateral skin-sparing mastectomy with one-stage reconstruction and free transplantation of the nipple-areolar complex.

Clinically, the patient’s mammary glands are symmetrical, ptotic, and there are no nodular formations in the area of the postoperative scar of the right mammary gland.

03/21/2024 bilateral subcutaneous mastectomy with one-stage reconstruction with a de-epidermized skin-fat flap and examination of the skin cover with indocyanine.

Under intravenous anesthesia, in accordance with the previously performed Wise skin marking on the mammary gland (Fig. 2), with the removal of the nipple-areolar complex (Fig. 3), the mammary gland tissue is removed subcutaneously (Figs. 4, 5), de-epidermization of the cutaneous-subcutaneous flap of the mammary gland is performed in the area of the lower and upper slopes (Figs. 6, 7). For the reconstruction of the gland volume, a de-epidermized cutaneous-subcutaneous flap of the sandwich type (in 3 layers) was used (Figs. 8, 9), which was placed in the area of the removed mammary gland and fixed with interrupted sutures to the pectoralis major muscle at the border of the upper quadrants (Fig. 11). The blood supply to the flap was preliminarily examined using intravenous administration of indocyanine (Fig. 10). Drainage was installed in the area of the formed mammary gland. The free nipple-areolar complex is fixed to the skin of the gland with interrupted sutures in the area of the central quadrants of the mammary gland at a level of 20 cm from the clavicle (Fig. 13, 14). Skin sutures on the mammary glands (Fig. 13).

An excellent aesthetic result of the mammary glands was achieved, no deformation of the glands was detected, nipple-areolar complexes without signs of necrosis, symmetry of the mammary glands was achieved. The operation time was 120 minutes. There were no intraoperative complications.

Routine histological examination:

Morphological conclusion of the surgical material dated 03/21/2024.

Macroscopic description:

1. The right mammary gland measures 15.5×14×3.4 cm, without skin and nipple. On the section, in the upper outer quadrant there is a thin-walled, smooth-walled cavity with a diameter of 2.5 cm (the area of the previous operation), in the wall of which a metal mark is installed. Along the rest of the length, the mammary gland tissue is represented by fatty tissue with thin whitish layers.

2. Left mammary gland tissue measuring 14×12×4 cm, without skin and nipple. No nodular formations on the section, presented as lobular adipose tissue with thin whitish layers.

Microscopic description

1. In the mammary gland tissue in the area described macroscopically, the cavity shows proliferation of granulation and "young" fibrous connective tissue, accumulation of giant multinucleated cells of the foreign body type. In the surrounding mammary gland tissue - foci of proliferating adenosis.

There is no tumor growth within the examined material.

2. In the breast tissue, a focus of hemorrhage, atrophy of ductal-lobular units, and atrophy of ductal-lobular units are determined.

There is no tumor growth within the examined material.

Morphological conclusion:

Conclusion The morphological picture corresponds to the clinical situation. There is no tumor growth within the examined material.

As a result of this operation, a bilateral skin-preserving mastectomy with one-stage reconstruction using a de-epidermized skin-fat flap and free transplantation of the nipple-areolar complex was performed. No postoperative complications were detected on the 7th day after the operation (Fig. 15 a, b, c).

The use of the claimed method in clinical practice allows:

- preserve the pectoralis major muscle and preserve the functional component of the muscle;

- perform a one-stage reconstruction of the mammary gland: remove a large volume of tissue with subsequent replacement with a de-epidermized skin-fat flap without the use of an endoprosthesis or muscle flaps;

- reduce the number of postoperative complications by using intravenous administration of indocyanine, and in the presence of ischemic zones in the de-epidermized skin-subcutaneous flap, intraoperatively excise the ischemic zones, and, as a result, the percentage of necrosis in the postoperative period decreases.

Claims (1)

A method of skin-preserving mastectomy with reconstruction using a de-epidermized skin-fat flap and free transplantation of the nipple-areolar complex in case of ptotic mammary glands, including de-epidermization of the skin-subcutaneous flap and its replacement of the removed mammary gland tissues, characterized in that an incision is made in the skin along the Wise markings, the nipple-areolar complex and mammary gland tissue are removed, de-epidermization of the skin-subcutaneous flap of the mammary gland is performed in the area of the lower and upper slopes, a de-epidermized skin-subcutaneous flap folded like a sandwich is placed in the area of the removed mammary gland and the blood supply to the flap is preliminarily examined using intravenous administration of indocyanine, then the flap is fixed with interrupted sutures to the pectoralis major muscle at the border of the upper quadrants, drainage is installed in the area of the formed mammary gland, a free The nipple-areolar complex is fixed with interrupted sutures in the central part of the mammary gland to the skin at a level of 20 cm from the clavicle, as shown in Fig. 13, the skin of the mammary gland is sutured.