Magnifying mammoplasty: implantation of spherical endoprostheses

Preoperative markup and access. Before the operation in the position of the patient, the median line and the submammary fold are marked and the boundaries of the tissue detachment zone, whose diameter should be slightly larger than the diameter of the prosthesis, are seated. From the side of the upper pole of the mammary gland, the zone of detachment of the tissues should be more by 2-3 cm.

Most often implantation of endoprostheses is performed through submammary, axillary (transaxillary), peri-and periareolar access. For the introduction of endoprostheses, already existing postoperative scars can be used. Each of these accesses has advantages and disadvantages.

The main advantages of submammary access are the possibility of an ideally accurate and symmetrical (on both sides) forming a pocket for the endoprosthesis, as well as the possibility of performing a thorough stop of bleeding. The length of such a cut, as a rule, does not exceed 5 cm, and its line corresponds to a submammary fold. The access marking is carried out as follows: the perpendicular from the nipple to the pectoral fold is dropped, then from the intersection of the lines, the points are marked 1 cm inward and 4-4.5 cm from the outside. It is important that the distance from the center of the areola to the pectoral fold is the same on both sides. On average, it varies from 6 to 8 cm and depends on the configuration of the chest and the planned volume of the prosthesis.

The advantage of axillary access is that the postoperative scar is in a hidden area. However, it is more difficult for the surgeon to form a cavity of appropriate size, to achieve a symmetrical arrangement of the prosthesis and careful stopping of bleeding.

The periareolar incision is located on the border of pigmented and light skin, which makes it less noticeable. Its shortcomings include a fairly frequent damage to the end fibers of the sensitive branch of the IV intercostal nerve, direct damage to the gland tissue, as well as restriction of the use of certain types of prostheses (prostheses filled with non-flowing gel).

Transareolar access has even more disadvantages. To the damage of the glandular tissue, microbial contamination of the formed pocket with microflora from the glandular tissue is added, which, according to modern ideas, is one of the reasons for the formation around the prosthesis of a powerful fibrous capsule.

Operation technique. The operation is performed under general anesthesia in the patient's position on the operating table on the back with hands drawn to the angle of 90 °. The tissue detachment zone is additionally infiltrated with a 0.5% solution of lidocaine with the addition of adrenaline at a dilution of 1: 200,000. With the use of a podder access, the skin and subcutaneous fatty tissue are dissected to the fascia of the large pectoral muscle, and then the cavity for the implant is formed. Depending on the location of the endoprosthesis, a pocket for it is formed over or under the large pectoral muscle. In accordance with the boundaries of the marking, the detachment of tissues above the muscle is performed between the leaves of the deep fascia, without damaging the fascial gland of the gland. Forming the cavity along the outer part of the gland, it is necessary to be extremely careful not to damage the anterolateral sensory branch of the IV intercostal nerve innervating the nipple-areolar complex. A certain advantage at this stage of the operation is the use of an electron knife with nozzles of various lengths. In the end, the size of the pocket should be slightly larger than the size of the prosthesis.

When the prosthesis is positioned under the large pectoral muscle, to prevent the implant from moving under the action of its contractions, the formation of the cavity is completed by cutting off the large pectoral muscle from its attachment to the sternum and the ribs.

The use of a head fiber fixture, good instrumentation and electrosurgical equipment is a prerequisite for performing a thorough bleeding stop.

After a check-up, the cavity is washed with a solution of antibiotic and antiseptic.

An important stage of the operation is the installation of an endoprosthesis in the formed bed. Mammoprostheses with a textured surface are inserted into the pocket with a special polyethylene "sleeve", so as not to injure the edges of the wound and not damage the surface of the implant. With the correct placement of the prosthesis, its center is usually located in the projection of the nipple, which is checked in the patient's position half-sitting on the operating table.

An obligatory element of the final stage of the operation is draining the wound with tubes (with active aspiration of wound contents). The subsequent application of sutures to the fascia requires the use of a blade by Buyalsky to protect the prosthesis from needle damage. After suturing the subcutaneous fat, an intradermal suture is placed on the skin - continuous or nodular. Complete the operation by applying an elastic compression bandage.

[1], [2], [3]