Method for preventing uncontrolled cranialization of pectoralis major muscle flaps during vertical myotomy in dual-plane augmentation mammoplasty

Abstract

FIELD: plastic surgery.SUBSTANCE: under aseptic conditions and endotracheal anesthesia, hydropreparation of the subcutaneous fat tissue is performed with 0.04% ropivacaine solution 60.0 ml with adrenaline 1:100000, a skin incision in the area of the submammary groove of the mammary gland of 3.5–4.0 cm in length is made, the tissues are dissected layer by layer to the fascia of the pectoralis major muscle. A dissection is performed in the Chassignac space to the level of the lower pole of the areola or an incision is made in the skin in the area of the mammary gland along the lower semicircle of the areola, the tissues are perpendicularly dissected layer by layer to the fascia of the pectoralis major muscle. Next, dissection is performed in the Chassignac space to the level of the submammary groove, and the lateral edge of the right pectoralis major muscle is isolated. The retropectoral pocket for the implant is formed using blunt and sharp methods. The lower medial bundle of the pectoralis major muscle is mobilized to the level of 4 o'clock on a conventional clock dial for the right breast and to the level of 8 o'clock on a conventional clock dial for the left breast. Partial vertical myotomy of the free muscle flap is performed. The distal fragments of the pectoralis major muscle are fixed at three points to the posterior surface of the gland with an atraumatic Vikryl 2-0 thread at the level of the nipple-areolar complex. A silicone implant is placed into the formed pocket, and the implant is evenly distributed and centered within it.EFFECT: preventing uncontrolled cranialization of the pectoralis major muscle flaps during vertical myotomy in dual-plane augmentation mammoplasty.1 cl, 2 ex

Description

[0001] The method for preventing uncontrolled cranialization of pectoralis major muscle flaps during vertical myotomy in dual-plane augmentation mammoplasty relates to the field of medicine, in particular to reconstructive plastic surgery.

[0002] Various implant placement options for augmentation mammoplasty are known in the art, including subglandular, retromuscular, subfascial, and dual-plane. Each option has its own drawbacks. However, dual-plane pocket placement provides long-term results that are unaffected by physiological changes in the mammary gland. Pocket formation is also easy to perform and is characterized by a minimal number of postoperative complications. (Tebbetts J.B. Dualplane breast augmentation: Optimizing implant-soft tissue relationship in a wide range of breast types. Plast Reconstr Surg 107: 1255, 2001).Dual-plane pocket formation involves making a skin incision along pre-marked lines, separating the glandular tissue from the pectoralis major muscle to the parasternal line. At the medial (sternal) border, the pectoralis major muscle is incised along the inferior-medial margin of the mammary gland, from 3 to 6 o'clock for the right breast (or from 6 to 9 o'clock for the left breast). The implant is then positioned in the created pocket such that in the area of ​​the lower quadrants of the mammary gland (from 3 to 9 o'clock for the right breast), the pocket wall is composed of mammary tissue and subcutaneous fat, and in the nipple area and above, it is composed of pectoralis major muscle, mammary tissue, skin, and subcutaneous tissue. The wound is sutured layer by layer to the skin level.

[0003] The dual plane implant pocket formation method has the following advantages: the implant does not move upward when the pectoralis major muscle contracts; more natural breast ptosis; low risk of developing a double bubble deformity.

[0004] This method has the following disadvantages:

[0005] - after the mammary glands have healed, an implant is palpated in the area of ​​the lower-inner edge of the mammary gland (this is due to a reduction in the integumentary tissue on the medial side after dissection of the pectoralis major muscle);

[0006] - also, when the pectoralis major muscle is tense, a transverse retraction of the lower semicircle of the nipple-areolar complex occurs, which greatly worsens the aesthetic appearance of the mammary glands.

[0007] The closest approach to the proposed method is the formation of a pocket for an implant in a dual plane during augmentation mammoplasty (RU Patent No. 2501528 C1 A61B 17 / 00, Bulletin No. 35, published: 20.12.2013), which involves making an incision in the skin and separating the glandular tissue and space behind the pectoralis major muscle to the parasternal line. The pectoralis major muscle is then dissected at the costal insertion site (in the area of ​​the lower-inner angle from 5 to 6 o'clock for the right breast). A vertical myotomy is performed perpendicular to the fibers of the pectoralis major muscle, from the lower free edge of the muscle to the upper level of the nipple-areolar complex projection onto the pectoralis major muscle.

[0008] This method allows for a more natural ptosis of the mammary glands, a low risk of developing a “double bubble” deformity, and there is no transverse retraction of the lower semicircle of the nipple-areolar complex when the pectoralis major muscle is tense, which worsens the aesthetic appearance, and the implant is not palpable in the area of ​​the lower-inner corner of the mammary gland.

[0009] However, this method has a drawback:

[0010] - When performing a vertical myotomy, two flaps of the pectoralis major muscle are created, which lie freely within the tissue. When the pectoralis major muscle is tense, they can shift cranially and grow into an aesthetically unfavorable position, especially if there is insufficient covering tissue;

[0011] - there is also a risk of implant inversion when the pectoralis major muscle contracts.

[0012] The technical result of the invention consists in preventing uncontrolled cranialization of the pectoralis major muscle flaps during vertical myotomy in augmentation mammoplasty in a double plane.

[0013] The technical result is achieved due to the fact that the method for preventing uncontrolled cranialization of the pectoralis major muscle flaps during vertical myotomy during augmentation mammoplasty in a double plane includes fixation of the distal fragments of the muscle flaps of the pectoralis major muscle after vertical partial myotomy to the posterior surface of the gland at three points with an atraumatic Vikryl 2-0 thread at the level of the nipple-areolar complex.

[0014] The proposed method for preventing uncontrolled cranialization of the pectoralis major muscle flaps when performing vertical myotomy in dual-plane augmentation mammoplasty is performed as follows.

[0015] Under aseptic conditions and endotracheal anesthesia, hydropreparation is performed with 60.0 ml of 0.04% ropivacaine solution with 1:100,000 adrenaline. A skin incision up to 4.0 cm long is made in the area of ​​the submammary groove of the right mammary gland, the tissue is dissected layer by layer to the fascia of the right pectoralis major muscle, dissection is performed in Chassignac's space to the level of the lower pole of the areola, or a skin incision is made in the area of ​​the right mammary gland along the lower semicircle of the areola, the tissue is perpendicularly dissected layer by layer to the fascia of the right pectoralis major muscle, dissection is performed in Chassignac's space to the level of the submammary groove. Next, the lateral edge of the right pectoralis major muscle is isolated, and a retropectoral pocket for the implant is formed using blunt and sharp dissection, taking into account its diameter. The inferomedial bundle of the pectoralis major muscle is mobilized to the 4 o'clock position and a partial vertical myotomy of the free muscle flap is performed.The distal fragments of the pectoralis major muscle are fixed at three points to the posterior surface of the gland with an atraumatic 2-0 Vikryl thread at the level of the nipple-areolar complex.

[0016] An Ulmer vacuum drain is inserted through the counter-incision and secured to the skin. A silicone implant is placed in the created pocket, evenly distributed, and centered. The wound is sutured with submerged sutures. A similar procedure is performed on the opposite side, with symmetrization elements, and a silicone implant is inserted. Submerged subdermal and intradermal sutures are placed with atraumatic 4-0 Monocryl sutures.

[0017] The effectiveness of the proposed method for preventing uncontrolled cranialization of pectoralis major muscle flaps when performing vertical myotomy in dual-plane augmentation mammoplasty is confirmed by clinical examples.

[0018] Example 1. Patient G., 43 years old, was hospitalized for planned surgical treatment with a diagnosis of asymmetry and bilateral post-lactation involution of the mammary glands, bilateral mastoptosis grade 0-1 according to Regnault. Complaints: no active complaints.

[0019] Medical history: after pregnancy, childbirth, lactation and breastfeeding, these complaints arose, she contacted the Swiss University Clinic, was consulted by a plastic surgeon, surgical correction was recommended, she was examined and prepared for surgical correction on an outpatient basis, and was hospitalized on a planned basis for surgical correction.

[0020] Laboratory test results: examined on an outpatient basis; no absolute contraindications for planned surgical correction were identified.

[0021] Instrumental examination data: examined on an outpatient basis; no absolute contraindications for planned surgical correction were identified.

[0022] Operation: bilateral augmentation mammoplasty with periareolar access.

[0023] Treatment: infusion, antibacterial, symptomatic and anti-inflammatory therapy; to prevent TEO, fraxiparine was used in a prophylactic dose, intraoperative variable pneumatic vasocompression of the lower extremities with the Kendall system, compression hosiery, and regular dressings.

[0024] Postoperative period: normal, typical, sutures are adequate, no trophic disorders in the mammary glands, drainage is functioning, compression garments are worn.

[0025] The patient is discharged in satisfactory condition under the observation of a plastic surgeon on an outpatient basis. At follow-up examinations 3 and 6 months after surgery, the cosmetic and functional results were rated as "excellent." No breast deformities were noted. Physical activity was fully restored.

[0026] Example 2. Patient Zh., 36, was hospitalized for planned surgery with a diagnosis of bilateral hypomastia. She has no active complaints. History of the disease includes age-related changes and congenital structural features. She visited a Swiss university clinic, consulted with a plastic surgeon, and was recommended for surgical correction. She was examined and prepared for surgical correction on an outpatient basis. She was then hospitalized for planned surgical correction.

[0027] Laboratory test results: outpatient examination; no absolute contraindications for planned surgical correction were identified. Instrumental test results: outpatient examination; no absolute contraindications for planned surgical correction were identified.

[0028] Operation: bilateral augmentation mammoplasty from submammary access.

[0029] Treatment: infusion, antibacterial, symptomatic and anti-inflammatory therapy; to prevent TEO, fraxiparine was used in a prophylactic dose, intraoperative variable pneumatic vasocompression of the lower extremities with the Kendall system, compression hosiery, and regular dressings.

[0030] Postoperative period: unremarkable, typical, sutures are adequate, no trophic disorders in the mammary glands, drains removed, compression garments.

[0031] The patient is discharged in satisfactory condition for outpatient observation by a plastic surgeon. At follow-up examinations 3 and 6 months after surgery, the cosmetic and functional results were rated as "excellent." No breast deformities were noted. Physical activity has been fully restored.

[0032] The proposed method for preventing uncontrolled cranialization of pectoralis major muscle flaps during vertical myotomy for dual-plane augmentation mammoplasty has the following advantage: the fixed flaps, when the pectoralis major muscle is tense, cannot shift uncontrollably and are fixed in the most advantageous position; the risk of cranial muscle displacement and implant eversion when the pectoralis major muscle contracts is also minimized.