Добавил:
Sekretar
kiopkiopkiop18@yandex.ru
t.me/Prokururor I Вовсе не секретарь, но почту проверяю
Опубликованный материал нарушает ваши авторские права? Сообщите нам.
Вуз:
Предмет:
Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_611_Библиотеки_им_академика_М_И_Перельмана
.pdf
266
https://t.me/medicina_free
C. G. M. de Lecea et al.
return into the initial breast shape and position
even more difcult after pregnancy. Consequently,
it is frequent to have postmaternity patients complaining about loss of the breast upper pole fullness and also some grade of ptosis.
15.2 Patient Selection
Patient candidates need to have the indications,
as well as be interested in breast reduction, NAC
repositioning, or breast lift separately or in
combination.
Breast reduction surgery is better performed
once the skin and breast tissue have stabilized.
Experienced plastic surgeons recommend to wait
for at least 6months after stopping breastfeeding
to undergo a breast reduction. It is believed that
within 6–12months, the body may readjust to the
changes related to pregnancy. If further pregnancies are contemplated, it would be important to
consider this surgery after the last pregnancy.
The American Society for Aesthetic Plastic
Surgery (ASAPS) and the American Society of
Plastic Surgeons (ASPS) recommend at least
3–6 months after breastfeeding or delivery for
undergoing breast surgery.
15.3 Preoperative Evaluation
15.3.1 Patient Considerations
The patients’ desires and expectations related to
breast reduction must be claried from the rst
medical consult. The surgeon would have to
select the best surgical planning in accordance to
the patient’s anatomy and considerations, as well
as explain what can be or cannot be achieved.
Smoking, patient’s preoperative body mass
index (BMI), medical history of hematological diseases, and medication or herbal therapies’ use also
have to be taken into consideration. All these factors
may inuence the outcomes and the risk of complications associated with a breast reduction surgery.
15.3.2 Physical Examination
As in any aesthetic and reconstructive breast
procedure, a thorough preoperative assessment
of the breast footprint on the thorax, the glandular tissue (cone), and the skin (the envelope)
is mandatory [16, 17]. These three aspects
allow the surgeon to evaluate the breast size or
hypertrophy, shape, ptosis grade, changes in the
inframammary fold position or asymmetries,
masses, or breast consistency, as well as the
skin quality and elasticity. Once these factors
have been dened, the surgeon is able to plan
and perform a systematic breast improvement
with aesthetically pleasing and reproducible
results.
The possible symptoms associated with breast
hypertrophy should also be collected in the rst
medical visit. Some surgeons talk about a syndrome dened as persistent neck and shoulder
pain with a tendency toward dorsal kyphosis,
shoulder growing from the brassiere straps, intertrigo rash on the inframammary fold, or even episodes of headache, back pain, and upper extremity
neuropathies. Others also refer psychosocial
impairment in terms of low self- esteem, body
image dissatisfaction, or sexual harassment.
Patients should be informed that even though
there has been no correlation between the breast
volume resection and the symptom relief, it is
well known that reduction mammoplasty has
shown improvement in general symptoms and in
quality of life [18].
The body mass index may be another important factor to be registered. Several studies have
demonstrated that the higher the body mass
index, the higher the risk of complications,
mainly those related to wound healing [19–22].
Nonetheless, the ASPS did not nd any conclusive evidence in the association between BMI
greater than 25 and higher risk of complications
[18]. Therefore, the surgeon must decide whether
patients on high BMI should be encouraged to
undergo a strict nutritional control before being
operated.
15 Reduction ofthePostpartum Breast
https://t.me/medicina_free
267
15.3.3 Screening Imaging
Preoperative screening mammography in healthy
and asymptomatic women undergoing breast
reduction is generally accepted. The American
College of Surgeons, the American Cancer
Society [23–25], and the American College of
Radiology recommend screening starting at
40 years of age. Scientic evidence supports
mammography among women younger than 40
only for those who have a high risk for breast
cancer [23]. Nevertheless, the U.S. Preventive
Service Task Force recommends biennial mammograms between 50 and 74years of age [26].
MRI is recommended as an adjunct to mammography in the case of a known BRCA mutation, if the rst-degree relative is known to have
the BRCA mutation but the patient is untested, or
if there is a lifetime risk of 20–25% of breast cancer [24].
Ultrasonography is also used as an adjunct to
screening mammography if needed.
15.3.4 Markings
Distance from the sternal notch to the nipple
and the meridian breast line should be equal and
range between 19 and 21cm. The lower areola
border-inframammary fold distance should measure 5–6 cm or up to 7–8 cm for big breasts.
Distance between the nipple and the middle line
should be around 9–12cm. Finally, the distance
between the middle line and the medial inframammary fold border should maintain a distance of
0.5–1.5 cm to avoid symmastia (intermammary
distance of at least 1–3cm).
Afterwards, the preoperative marks can be
systematically drawn beginning with the standard measure lines and then continuing with the
specic surgical pattern markings.
Standard Measure Lines
First: The middle line is drawn from the sternal
notch to the upper border of the umbilicus.
Second: The inframammary fold is drawn and
then a line that connects both lower portions
of the inframammary folds.
Third: The ideal new nipple position is generally
marked at Pitanguy’s point (Fig. 15.3). The
The surgeons must keep the ideal breast measurements in mind while marking the breast reduction patterns (Fig.15.2).
Fig. 15.2 Ideal breast measurements
Fig. 15.3 Pitanguy’s point. This point is measured by
palpating the inframammary fold with the nger pointing to the breast meridian line and then, with the other
hand, transposing it to the overlaying breast (Reproduced
from the book “Breast Surgery. Aesthetic Approaches”.
Editor Juarez Avelar M. Springer. 2018. ISBN
978-3-319-54115-0)
268
https://t.me/medicina_free
C. G. M. de Lecea et al.
new nipple position is expected to descend
slightly with time. The surgeon should keep in
mind that the standard nipple position is
slightly below the middle line of the breast
mound and it points a bit lateral and downwards to make the marking readjustments as
needed if in doubt.
Fourth: Then the breast meridian is marked bilat-
erally through the ideal new nipple position
and it is continued through the abdomen. It
starts at 7cm from the clavicular medial edge.
Specic Surgical Pattern Markings
• Periareolar (Fig. 15.4):
– First: Following the procedure explained
above, the new nipple position is marked.
– Second: The new upper areola border is
drawn 2cm above the new nipple position
along the breast meridian line.
– Third: The lower areola border should be
7–8 cm above the inframammary fold
along the breast meridian line.
– Fourth: Then a peripheral outline circum-
ference is marked depending on the skin
excess. The medial point is designed by
gently displacing the breast laterally and
marking the medial point where the breast
meridian is transposed.
– Fifth: The same approach but with the
breast moved to the medial side is performed for designing the lateral point.
– Sixth: The four points are then
connected.
• Vertical pattern (Fig. 15.5):
– First: Following the procedure explained
above, the new nipple position is marked.
– Second: Then the new areola is drawn in
accordance with the total new areola diameter. A total circumference of 16 cm
matches a 5cm diameter, and a 14cm circumference matches a 4.5cm diameter.
– Third: Afterwards, both vertical lines are
drawn regarding the breast vertical pinch
test and in a “U” shape.
Fig. 15.4 Markings of a periareolar pattern. (a)
Preoperative markings. The red lines delimit the clavicle
gure, middle line, inframammary folds, bilateral
connection, and abdominal continuation of the breast
meridian line. The blue lines highlight the breast meridian
line in which the new nipple position is located; the
intermammary distance (which has to measure between 1
and 3cm) and the distance between the abdominal breast
meridian and the middle line should range between 11 and
13cm. The black lines refer to the periareolar markings.
(b) Postoperative scars. The periareolar pattern results in
only periareolar scars
15 Reduction ofthePostpartum Breast
https://t.me/medicina_free
269
Fig. 15.5 Markings of a vertical pattern. (a) Preoperative
markings. The red lines delimit the clavicle gure, middle
line, inframammary folds, bilateral connection, and
abdominal continuation of the breast meridian line. The
blue lines remark the breast meridian line in which the
new nipple position is located; the intermammary distance
Fig. 15.6 Markings of an inverted T pattern with a superomedial pedicle. (a) Preoperative markings. Red lines
delimit the clavicle gure, middle line, inframammary
folds, bilateral connection, and abdominal continuation of
the breast meridian line and the superomedial pedicle.
Blue lines remark the breast meridian line in which the
new nipple position is located; the intermammary distance
(which has to measure between 1 and 3 cm) and the
(which has to measure between 1 and 3 cm) and the
distance between the abdominal breast meridian and the
middle line should range between 11 and 13 cm. The
black lines refer to the vertical pattern. (b) Postoperative
scars. The vertical pattern results in periareolar and
vertical scars
distance between the abdominal breast meridian and the
middle line should range between 11 and 13 cm. The
black lines correspond to the new nipple-areola complex,
the vertical and horizontal lines of both the medial and
lateral pillars, and the inferior incision. (b) Postoperative
scars. The inverted T pattern results in periareolar, vertical,
and horizontal scars
• Inverted T pattern (Video 15.1; Fig. 15.6):
– First: Following the procedure explained
above, the new nipple position is
marked.
– Second: The new upper areola border is
drawn in accordance with the total new
areola diameter, which usually encompasses between 38 and 45mm.
270
https://t.me/medicina_free
C. G. M. de Lecea et al.
– Third: The vertical incisions of both skin
aps are marked following a line from the
new upper areola border and the breast
meridian line. These vertical lines are the
sum-up of the areola diameter and the new
distance between the inferior areola border
and the inframammary fold. Their length
usually varies from 9 to 12cm. Their angle
ranges from 60° to 120° degrees depending
on the size of the breasts.
– Fourth: Finally, the horizontal limbs of
both skin aps are marked. They must
match the total horizontal length of the
inframammary fold. It is recommended to
pinch both vertical limbs together and
make sure that the closure will not have
much tension.
General Key Points
All patients should be marked preoperatively in
the standing and anterior facing position with
both upper limbs relaxed and adducted.
The intermammary distance should be in
between 1 and 3cm to avoid symmastia.
Due to gravity and time-related changes, the
new nipple-areola position should be 1cm lower
to the inframammary fold if there is an empty
upper breast pole and may be 1 cm elevated if
there is a full upper pole.
Key Point for Inverted T Pattern
Smaller and more ptotic breasts would benet
from a smaller angle between the vertical lines to
avoid excessive skin removal.
It is important to match the horizontal length
of the medial and lateral skin aps to the incision
in the inframammary fold. The sum of both horizontal sides should be equal or a bit less than the
inframammary incision to avoid the medial and
lateral dog-ear.
Key Point for Periareolar Pattern
This technique should be considered in pseudoptosis, grade 1 breast ptosis, and small breast
reductions with a good skin quality.
15.4 Anesthetic Considerations
15.4.1 Outpatient Versus Inpatient
Procedure
It was around the 1990s when some plastic surgeons started to perform outpatient reduction
mammaplasties in an attempt to decrease the
complication rate and the costs of the surgical
procedure [22, 27–29]. Carpelan or Stevens demonstrated a saving between 18 and 50% in comparison to inpatient-based reduction
mammaplasties, from a total average cost of 5039
euros to 4114 euros, respectively [30]. Moreover,
no signicant differences existed in complication
rates between inpatient and outpatient groups
[22, 29]. Nowadays, both surgical options are
available but should always be performed in
well-accredited facilities.
15.4.2 Antibiotic Prophylaxis
Currently, evidence supports the use of perioperative antibiotics to reduce the infection associated with breast reduction mammoplasty [18,
31–33]. Some studies advocate for a single pre-
operative antibiotic dose [31]. However, due to
the lack of evidence ndings, a recommendation
cannot be made on antibiotic prophylaxis timing
or duration [18, 32].
15.5 Surgical Technique
Key Point for Vertical Pattern
The lower edge of the vertical marking must rest
at a minimum of 2cm above the inframammary
fold, to avoid the scar from falling below it.
15.5.1 Patient Positioning
The patient must be prepared to an intraoperative
seating position for optimizing and comparing
15 Reduction ofthePostpartum Breast
https://t.me/medicina_free
271
bilateral breast results after glandular and skin
resections. The patient can be prepared both with
the upper limbs abducted or adducted, but the
former positioning allows a better view and
approach of the lateral border of the breast. An
accurate symmetry in the position of the arms
and shoulders must also be maintained during the
surgery.
15.5.2 Approaches
The surgical approaches depend mainly on the
amount and quality of the excess skin. There are
ve main patterns:
• Liposuction-only reduction mammaplasty:
This technique approach involves minimal
skin incisions through which to perform the
liposuction. This standard liposuction does
not involve the use of a pedicle for nipple
blood supply, and it also leaves intact the
breast nerves. For similar reasons, breastfeeding potential is not typically compromised. In
addition, this technique permits a slight elevation of the nipple and tightening of the skin.
The recovery from liposuction-only reduction
mammaplasty can be quite signicant, and it
can take about 6weeks for bruising and swelling to decrease and about 6 months for the
breast to soften and for lumpiness to settle.
Liposuction-only reduction mammaplasty
works well when breast tissue is mostly fat
and thus has limited usefulness in those
patients in whom breast is more glandular,
such as teenagers [34–36].
• Horizontal pattern:
This procedure is also known as the no-
vertical scar breast reduction. Similar to an
abdominoplasty, a large skin horizontal resection is made, followed by a periareolar incision to detach the nipple-areola complex and
then gather the superior skin ap to the inframammary fold. Afterwards, a new circumferential incision is made on the skin ap to
expose again the nipple-areola complex. This
technique involves the use of an inferior pedi-
cle and the absence of vertical breast parenchyma or skin resections.
• Periareolar pattern:
This is only indicated in small breasts,
Regnault breast ptosis classication grade I,
and patients with elastic skin. Its dissection
allows the maintenance of the breast and nipple-areola complex vascular nervous supply
and the breastfeeding function. However, it
involves the release of the skin from the glandular tissue, reduces and readapts the breast
gland depending on the pedicle employed, and
then sutures the skin back to the areola under
tension.
• Vertical pattern:
It is mainly employed in small-to-moderate
breast hypertrophies with a good skin quality.
Any pedicle can be adjusted to this skin reduction approach, but the most common are the
superior, medial, and lateral.
• Inverted T pattern:
It is the most common technique for big-
sized breast reductions and in patients with
nonelastic redundant skin in those who are not
possible to readjust the breast shape without
further skin resection. The different pedicles
can be adjusted to this pattern.
Tip
Periareolar and liposuction-only procedures have
specic indications.
15.5.3 Procedure Step-by-Step
oftheInverted T
andtheVertical Procedures
• Vertical pattern:
– First: The areola is marked with a
38–45-mm-diameter nipple marker.
– Second: The pedicle is de-epithelized, and
0.5–1cm of tissue around the areola is left.
The pedicle is created full thickness down
to the breast meridian.
– Third: The vertical incisions are then made.
The skin cover is released from the gland
with a 0.5–1 cm thickness all around the
272
https://t.me/medicina_free
inferior breast pole up to the mid-horizontal nipple axis.
– Fourth: Then a wedge of breast is resected
in the inferior breast pole.
– Fifth: The medial and lateral pillars are
sutured together in the midline without
tension and with interrupted 3-0 Novosyn
stitches.
– Sixth: The skin is closed without tension
with interrupted 3-0 Novosyn for deep
planes and with intradermal 3-0 Monocryl
stitches.
• Inverted T pattern (Video 15.2):
– First: The areola is marked with a
38–45-mm-diameter nipple marker.
– Second: The pedicle is de-epithelized
around the new areola and the vertical incision. In our institution, the superomedial
pedicle is the most performed.
– Third: Afterwards, both vertical incisions
are made and the intervening superior and
lateral periareolar breast tissue is dissected
down to the pectoralis major fascia.
– Fourth: Then the inferior and both horizon-
tal incisions are performed. The excess
breast is removed along the pectoralis
major fascia to the superior incisions.
– Fifth: Both the medial and lateral breast
pillars are brought together to the midline
and sutured with interrupted 2-0 and 3-0
Novosyn to reduce tension on the vertical
closure.
– Sixth: A 38–45-mm-diameter areola
marker is used to mark the nal placement
of the areola after the rotation of its pedicle
(Fig. 15.7), and the periareolar tissue is
then de-epithelialized.
– Seventh: The areola is uncovered and inset
with interrupted 3-0 Novosyn and intradermal 3-0 Monocryl sutures.
– Eighth: The rest of the skin defects are
closed in two layers with interrupted 2-0
and 3-0 Novosyn and intradermal
Monocryl 3-0 sutures.
C. G. M. de Lecea et al.
Fig. 15.7 This gure shows a superimposed image of a
preoperative and postoperative case. Note the rotation of
the pedicle demonstrated by the new position of the mole
(green arrow)
15.5.4 Surgical Modications
15.5.4.1 Combined Breast Reduction
Augmentation
A common problem shared by the different breast
reduction techniques is that with time and due to
gravity effect the breast gland tends to fall into
the lower pole resulting in a bottoming-out sign.
This means a loss of the upper pole fullness
which becomes a non-projecting breast with
pseudoptosis. The breast reduction augmentation
is a technique which combines both the breast
reduction and the use of breast implant in an
attempt to maintain the breast shape in the late
postoperative period [37]. This procedure combines either the inverted T or the vertical patterns
with a total subpectoral implantation of a round
silicone breast prosthesis. This surgery seems to
provide a natural and lasting upper pole fullness
with complication and revision rates similar to
the conventional breast reduction techniques.
15 Reduction ofthePostpartum Breast
https://t.me/medicina_free
273
15.5.4.2 Internal Breast Fixation
Internal breast devices for avoiding or preventing
recurrent ptosis after mammoplasty have been
described [38, 39]. These devices are commonly
made of silicone sheets or absorbable mesh [39].
The GalaFLEX scaffold is an example of a Food
and Drug Administration-approved mesh, composed of resorbable poly-4-hydroxybutyrate
(P4HB) monolaments, that is usually placed on
a subpectoral breast implant [38]. It allows tissue
ingrowth into its pores toward the implant and
permits the formation of a strong and pliable capsule that supports the elevated breast prole over
time [38]. Even though it has demonstrated economical and better integration advantages compared with acellular dermal matrixes, only
24months of follow-up have been recorded following ptosis correction.
The internal bra system is also a 3D preshaped
woven polyester mesh that has demonstrated to
be a strong, stretchable, and non-palpable mesh
[39]. It is placed under the breast skin and xed
high up to the second rib junction and to the pectoral fascia with nonabsorbable sutures or staples,
preventing its dislocation, curling up, or migration [39]. It has demonstrated good outcomes in a
4.5-year-follow-up study. It also seems not to
interfere in X-ray or physical examinations.
However, its use during pregnancy, lactation,
local infections, irradiation, and previous subglandular augmentation has been considered
absolute contraindications [39].
Even though these devices seem to be promising in breast surgery, complications such as
infection or abscess formation, rippling, small
partial extrusion, or interference in sentinel node
diagnosis have to be considered when using
them.
Further investigation and longer term followup studies are needed to recommend these
devices and prove that their results are stable over
time.
15.5.5 Technical Tips toImprove
Outcomes andAvoid
Complications
• Vertical pattern:
The vertical pattern should never be closed
with tension, to avoid wound healing
problems.
The vertical dog-ear can be matched in two
manners. Conservative treatment is the best
option for small skin excess, as the incision
stretches out with time. Larger puckers can be
corrected intraoperatively by adding a further
small skin resection horizontally, becoming a
small inverted T pattern.
• Inverted T pattern:
A free nipple graft is usually used when the
sternal notch distance exceeds 35–37cm.
An oblique dissection of the breast tissue
along each horizontal incision is recommended to fulll a rounder and fullness inferior pole. This dissection achieves an attractive
and anatomic breast prole (Fig.15.8).
Sometimes, medial and lateral wedge
resection are performed to diminish the breast
width.
Since the inverted T pattern relies on the
skin as a brasserie, skin closure under some
tension is acceptable.
15.5.6 Anatomopathological
Examination
All breast tissue removed from women older than
40 years or from those with personal or family
history of breast cancer at any age should be sent
to pathology for microscopic analysis [23, 40].
The incidence of occult breast cancer in reduction mammoplasty specimens most closely
approximates 1% [23, 41]. Invasive ductal carcinoma is the most common malignant lesion iden-
274
https://t.me/medicina_free
Fig. 15.8 Preoperative
(left) and postoperative
(right) pictures of a case
operated by using an
inverted T pattern. An
oblique dissection of the
breast tissue along each
horizontal incision was
done to fulll a rounder
and fullness inferior
pole, achieving an
attractive and anatomic
breast prole
C. G. M. de Lecea et al.
tied, but DCIS, lobular carcinoma in situ,
Paget’s disease, and brosarcoma have also been
reported less frequently [23, 41–43].
15.6 Postoperative Care
15.6.1 Drains
The main usefulness of drains remains in the avoidance of uid and blood accumulation in the dead
space from tissue removal. Drains are generally
removed when the output is less than 50cc in a 24to 72-h period. However, several studies have
reported that the use of surgical drains after breast
reduction does not result in any signicant difference in wound healing nor hematoma rates [44–47].
Moreover, drains may increase postoperative patient
discomfort and anxiety due to the “pinching” pain
at the drain exit side, the ache with the drain
removal, and the scar left on the drain exit [18].
15.6.2 Wound Care
Surgeons may cover the skin incisions with different wound dressings such as sterile tape. The
wounds should be kept dry at least during the rst
24–72h to allow the wound seal. Afterwards, the
patients are allowed to shower and are explained
to perform a simple wound care based on a proper
drying of the incision, followed by the application of an aseptic solution and then a new cover
with a simple wound dressing. This wound care
should be maintained until the stitch removal in
2weeks.
15.6.3 Surgical Brasserie
andAdjustable Stretch
ChestBand
Most surgeons use surgical brassieres during
2–4weeks postoperatively. The aim is to provide
some type of support while also avoiding excessive compression that may compromise the nipple blood supply. Other surgeons also employ
orthopedic bands laying over both inframammary folds to keep them in place until its healing
xation to skin occurs.
15.6.4 Venous Thrombosis
In accordance with the American Society of
Breast Surgeons consensus guideline, the aggre-
15 Reduction ofthePostpartum Breast
https://t.me/medicina_free
275
gate DVT risk for breast surgery is less than 0.4%
in more than 100,000 patients [48]. The risk is
highest in patients undergoing mastectomy with
immediate autologous reconstruction and also in
patients older than 65years, in obese patients, in
surgeries longer than 3h under general anesthesia, when it is a cancerous etiology, if it implicates a long hospital stay, and if the patient has
undergone a previous surgery within the last
30 days. Chemoprophylaxis should be considered in this type of patients. On the other hand,
the American Society of Breast Surgeons recommends no specic VTE prophylaxis in patients
undergoing breast operations under local or
regional anesthesia. However, preventive standard algorithm with compression devices and
early ambulation regimen should be started since
the rst night after surgery in cases undergoing a
breast operation with general anesthesia without
immediate reconstruction [22, 48].
In our institution, when it is indicated, patients
below 70kg are administered 2500U of subcutaneous heparin and those who weigh more than
70kg are given 3500U of subcutaneous heparin
daily during the rst 2 postoperative weeks.
plications, specially those associated with infection [50].
15.7.2 Wound Care
Once the stitches are removed, patients are
encouraged to hydrate their wounds and protect
them from sun exposure during the rst postoperative year to avoid wound hyperpigmentation
complications.
15.7.3 Follow-Up
Patients are followed up in the clinics at 15days
and 1, 3 (Fig.15.9), 6, and 12months postoperatively. The most reliable outcomes are noticed
3months after surgery (Figs. 15.10 and 15.11).
Further patient considerations and surgeon
reviews are then evaluated and recorded with the
patient physical examination and standard follow-up photographs.
15.7.4 Breast Postsurgical Changes
15.7 Outcomes andPrognosis
15.7.1 Smoking
Even though smoking is related to higher risk of
wound complications in general, there are studies
which have not found statistical signicance in
breast reduction outcomes [22, 49]. On the other
side, some studies suggest to quick smoking
before undergoing a breast reduction surgery
because it is an independent risk factor for com-
Fig. 15.9 From left to right, preoperative picture and 15days, 1month, and 3months after the procedure. Note how
the lower pole is rounder and rounder and the change in the orientation of the nipple-areola complex
Postsurgical changes in the breast after reduction
mammaplasty encompass a variety of physical
and radiographic manifestations [51–53]. Fat
necrosis, oil cysts, brosis, organizing hematoma, calcications, and, rarely, concurrent
malignancy should be considered in this type of
patient [51]. On presentation of a breast mass
after reduction mammaplasty, a diagnostic protocol is used to determine whether operative intervention is appropriate, to avert unnecessary
biopsy and to avoid overlooking breast malig-
Соседние файлы в папке Библиотека им академика М.И. Перельмана