новая папка / 450-550 operativ

Toilet mastectomy is done in locally advanced tumour with removal of tumour and possible breast tissue to prevent fungation.

Extended radical mastectomy is doing radical mastectomy with removal of internal mammary nodes of same side or opposite side. It is not practiced.

Nipple sparing mastectomy is done with preservation of nipple and areola.

Areola sparing mastectomy is done preserving areola with resection of the nipple.

RECONSTRUCTION OF THE BREAST

Breast reconstruction is done either as immediate or delayed procedure. Immediate reconstruction is done in early breast cancer or after prophylactic mastectomy. Reconstruction is delayed for 6 months in advanced cases.

Fig. 16-39: Double tube silastic drain is kept. One tube is in front of the pectoralis major muscle; other in the axilla. Bulky dressings with elastic bandage support are usually used. Drain is removed once drainage is less than 30 ml per day for two consecutive days.

Skin is closed primarily as wound closure. If skin is removed widely and apposition is not possible then skin graft is ideal as it will tolerate radiotherapy very well (Fig. 16-41).

Implant is placed under the pectoralis major, serratus anterior, external oblique and rectus abdominis myofascial plane (Fig. 16-42).

Myocutaneous ap with or without breast implant in submuscular planeis goodreconstructive approach.Latissimus dorsi myocutaneous ap (LD FLAP) or Transverse abdominis myocutaneous aps (TRAM FLAP) are used with or without implants. LD ap usually needs

implant. TRAM ap dose not require implant usually.

Silicone gel implant under pectoralis major muscle or expandable saline prosthesis may be used. Placement of implants is technically easier. One should take care to achieve symmetry. Complications of implants are pain, rupture, displacement, infection and capsular contracture.

TRAM ap can be standard lower TRAM or upper TRAM. Vertical RAM ap is also used as variation. Contralateral submammary ap is also used.

Factors deciding the reconstruction are – amount of skin retained; stage of carcinoma; need of radiotherapy or earlier radiotherapy; need for implant.

Standard lower abdominal TRAM ap is placed horizontally with upper incision at the level of umbilicus; lower incision below su-

Fig. 16-41: Split skin graft is done after mastectomy on one side. Other side primary closure was done. It was a bilateral carcinoma of breast.

Fig. 16-42: Breast implant used for reconstruction. It is placed either subcutaneous or submuscular plane.

be used to revascularise through internal mammary artery. Deep inferior epigastric perforator ap (DIEP) is used as a free ap in breast reconstruction. Revascularisation is done using internal mammary or thoracodorsal vessels (Figs 16-45 and 16-46).

Latissimus dorsi muscle/myocutaneous flapIt is based on thoracodorsal artery, a branch of subscapular artery. Skin over the upper and anterior border of the muscle is used for transfer. It is commonly used to cover the defect after mastectomy. But it does not give the bulk. It is technically easier. It can be used as muscle flap also. It helps as skin cover. Prosthesis (submuscular silicone) is needed to place underneath to provide bulk in postmastectomy defect. Muscle arises from iliac crest upwards to midthoracic spine. Muscle is like a fan below forming tendinous fibres above to insert into humeral shaft. Subscapular artery a largest branch is derived from 3 part of axillary artery runs along posterior wall of the axilla giving circumflex scapular vessels at 4 cm distance and later continues as thoracodorsal artery for about 6 cm, enters the muscle giving many branches. Flap is usually taken as myocutaneous flap with elliptical skin on the surface. Skin part is either horizontal ellipse when taken from upper margin of the muscle or vertical when taken from the anterior margin of the muscle. Point of origin of the subscapular artery is the pivot point of the flap. Artery is accompanied by the vein. While raising the flap after islanding it with skin, only pedicle can be retained cutting muscle above to attain extra length (but commonly anterior attachment is retained) and flap is rotated to the needed area. Donor area can be sutured primarily or covered with a split skin graft. Often in LD flap nerve is not retained (if retained it causes unpleasant muscle contractions and so it will not maintain the bulk but gives good coverage of the defect). Flap harvesting is done in lateral position. Subscapular vessels maintain the adequate length and caliber and so it is often used as free flap based on subscapular vessels (Fig. 16-47).

can occur.

FreeTRAMflapintointernalmammary/ thoracodorsal axis canbedone Limitations to position, shape and rotate; needs mesh placement in the abdomen woundto prevent the formation of incisional hernia

Nipple is created using— Local breast aps, 3 months after breast reconstruction; nipple sharing from contralateral nipple using composite graft; skate ap: local ap with de-epithelialised donor site around the periphery over which a full thickness graft is applied; nipple prosthesis.

Areola pigmentation is created using (it is done 3 weeks after nipple creation) – Full thickness skin graft from non-hairy skin lateral to labia majora, as the pigmentation of this graft matches that of the areola; from contralateral areola if reduction mammoplasty is done on that side; tattooing – colour tends to fade with time and may need to be repeated; split skin graft from retroauricular area or from thigh.

Chapter

17

SURGICAL ANATOMY OF PAROTID PARA – AROUND; OTIC – EAR GLAND

Parotid, pyramid shaped largest of salivary glands (15 gram) is located below the external acoustic meatus, between ramus of the mandible and the sternomastoid. Gland overlaps these structures and masseter muscle. Gland is of ectodermal origin.

Surfacemarkingofthegland:Linejoiningfromapointatuppermargin of mandibular head; along a point at the center of the masseter muscle; toa point atposteroinferior angle ofthemandible and ata pointat upper part of anterior margin of the mastoid process. Parotid duct is marked in the middle third of a line joining the lower border of tragus to a point which is at themiddle of the line joining the nasalala to marginof upper lip. Facial nerve is marked from a point at middle of the anterior border of mastoid process (stylomastoid foramen lies 2 cm deep to this point) to a point behind the neck of the mandible (Fig. 17-1).

Investinglayer ofdeep fasciaofnecksplitsatthelowerposteriormargin of the gland into two layers, as a thick adherent super cial lamina, and a thin deep lamina. Super cial part is attached to zygomatic arch above. Parotid capsule otherwise is super cial lamina is thick, inelastic and unstretchable. Deep lamina is attached to styloid process, mandible, and forms thick stylomandibular ligament to separate it from submandibular salivary gland (Fig. 17-2).

Surgeries of

Salivary Glands

Anteromedial surface is related to masseter, lateral part of temporomandibular joint, posterior margin of the mandibular ramus, medial pterygoid, branches of facial nerve. Posteromedial surface is related to mastoid process, sternomastoid, posterior belly of digastric musle, styloid process. External carotid artery enters the gland through this surface. Internal carotid artery is deep to styloid process.

Parotid gland is divided conventionally into two lobes – super cial lobe (80%) is also called as exofacial lobe which is outer to facial (7th cranial) nerve plane; deep lobe (20%) is also called as endofacial which is deeper to facial nerve plane. Deep lobe is located adjacent to masseter muscle along the ascending ramus of the mandible. Isthmus of the parotid is that portion which is between temporofacial and cervicofacial branches. Tail of the parotid is the portion which extends posteroinferiorly over mastoid tip and sternocleidomastoid muscle

(Figs 17-3 and 17-4).

Fig. 17-3: Lobes of parotid.

Fig. 17-4: Relations of the parotid gland.

Parotid gland is bounded above by zygoma, below by styloid process, styloidmuscles,internalcarotidarteryandinternaljugularvein,behindby externalauditorycanal.Fasciadeeptodeeplobeisextensionofthefascia from deeper part of the digastric muscle and is called as stylomandibular membrane which occupies between mandible in front, styloid process behind and stylomandibular ligament below. This membrane separates parotid from submandibular salivary gland. Deep lobe tumour extends to parapharyngeal space through this membrane.

Structures passing through the anterior margin are – parotid duct, facial nerve branches and transverse facial vessels.

Structures within the parotid gland are –Arteries (deepest) – ECA enters the gland through posteromedial surface of the gland; maxillary artery (begins at neck of the condylar process of mandible) leaves the gland through anteromedial surface of the gland medial to gland to reach infratemporal fossa; super cial temporal artery comes out through superior surface passing between external acoustic meatus and TM joint to reach temporal fossa where it is accompanied by auriculotemporal nerve. Transverse facialarteryarisesfromsuper cial temporal artery runs horizontally above the parotid duct. Posterior auricular artery arises from ECA passing posteriorly deeper and at upper margin of the posterior belly of digastric to reach posterior auricular region. Posterior auricular artery gives stylomastoid branch which runs in front and along the facial nerve to enter the stylomastoid foramen to supply tympanic cavity, mastoid air cells and semicircular canals. Veins (outer to arteries) – super cial temporal vein and maxillary vein (formed by pterygoid venous plexus at lateral pterygoid muscle) joins to form retromandibular vein (posterior facial vein/temporomaxillary vein) within the gland which descend and divides into anterior and posterior divisions which emerge at apex of the gland; anterior division after emerging joins facial vein to form common facial vein which runs super cial to digastric to reach IJV; posterior division joins the posterior auricular vein to form external jugular vein which runs downwards in front of posterior belly of digastric muscle, sternocleidomastoid, great auricular nerve to reach subclavian vein. Patey’s faciovenous plane is important during surgical dissection. Facial nerve (outer to venous plane) – comes out of stylomastoid foramen where it is accompanied with stylomastoid branch (in front of facial nerve) of posterior auricular artery (artery enters, nerve comes out). Here it gives posterior auricular branch to supply posterior auricular and intrinsic muscles of the ear and branches to posterior belly of digastric and stylohyoid. Nerve after traveling for 1 cm enters the gland through its posteromedial surface and again runs for 1 cm in the gland dividing within gland into two terminal branches – zygomaticotemporal (larger) and cervicofacial (smaller). Terminal temporal (auricularis anterior and superior part of frontalis) and zygomatic (frontalis and orbicularis oculi) branches arise from larger zygomaticotemporal division. Upper buccal, lower buccal (buccinator, orbicularis oris and elevators of lip), marginal mandibular (lower lip muscles), cervical (platysma) arise from smaller cervicofacial branch/division whichemerge through the anteromedial surface. Multiple communications are common between branches especially in zygomatic and temporal branches (pes anserinus/goose foot). ey supply muscles of facial expression and platysma. Deep parotid lymph glands – ey are embedded in the super cial lobe of the gland. Faciovenous plane of Patey is a plane where vein and facial nerve branches lie within the parotid with nerve lying super cial to vein in this plane (Figs 17-5 and 17-6).

Parotid duct (Niels Stenson’s—Anatomist Copenhagen; father of geology) is 5 cm in length (2-3 mm diameter) with thick wall which after

Fig. 17-5: Structures passing out of the parotid gland.

Fig. 17-6: Patey’s faciovenous plane.

beginning at deep and behind the angle of mandible 1.5 cm below the zygoma runs forwards and emerges from the anterior border running forward and downward on the masseter muscle up to its anterior margin where it pierces obliquely the buccal pad of fat, buccopharyngeal fascia, buccinator muscle and opens into the vestibule of the mouth opposite the crown of 2nd upper molar tooth. During its course it receives interlobular from above and one duct from accessory parotid gland. Above it is related to accessory parotid gland, upper buccal branch of facial nerve, transverse facial vessels; below to lower buccal branch of the facial nerve (Fig. 17-7).

Blood Supply

Parotid is supplied by ECA through its direct branches and also branches of ECA in the parotid region; venous drainage is into the external jugular vein (Figs 17-8 and 17-9).

Lymphatic Drainage

Fig. 17-7: Accessory parotid gland is above the parotid duct.

Fig. 17-8: Arterial supply of parotid gland and arteries related to parotid.