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_884_Библиотеки_им_академика_М_И_Перельмана
.pdf
Fig. 7.19
https://t.me/med1917
7 Breast Surgery
Fig. 7.20
295
7 Breast Surgery
https://t.me/med1917
Dressing (Fig. 7.21)
䊏
After wound closure, the incisions are closed using Steri-Strips™ that
the patient may remove herself after 8 days. In addition to the dressing,
smallpiecesofgauzeand10×15cmCutiplastplastersareappliedto
thenipples,anda10×10cmfoldedpressuredressingand10×15cm
Cutiplast plaster are applied to the inframammary incision. Subsequently, a bandage is used for postoperative compression. After 2 days
this is changed to a sports bra of the appropriate size.
Aftercare
䊏
After the operation, the patient is monitored for 24 h. The blood pressure is monitored and it ought not to be above 120 mg systolic. During
this time, the patient must stay in bed on her back with the upper body
raised by 30°. The first day after the operation the Redon drain is
removed and the bandage is changed. If the course of the recovery is
without problems, the patient is given a well-fitting sports bra. This is
adjusted in the clinic and the patient must wear it at home for 4 weeks.
Where the implant is beneath the muscle, we recommend that the
patients wear a ‘Stuttgart belt.’ This reduces muscle swelling, produces a
supple connective tissue site (long-term study from the USA) and accelerates the conto uring process.
296
For the first 8 days after the operation, the patient receives an antibiotic
(cefaclor) and triamcinolone acetonide tablets, 8 mg per day. After 8
days, the patient can remove the Steri-Strips herself. The incisions must
be taken care of for 2 weeks using dexpanthenol ointment, and after 4
weeks silicone gel must be used or a plaster applied for 2 months. Four
weeks after the operation, it is possible to do heavy physical work and
sport. Social activities and work do not pose a problem after 8 days.
Patients are requested to go to the breast clinic immediately if there are
any problems. After 12 months, there will be a final check with precise
photo documentation.
Fig. 7.21
https://t.me/med1917
7 Breast Surgery
297
7 Breast Surgery
https://t.me/med1917
7.1.2 Submuscular Access (Fig. 7.22–7.27)
This operation technique is indicated when the skin and glandular
tissue are unfavorable and too thin: if the implants were incorporated
above the muscle, the skin covering would be too thin and rippling and
the impressio n of an implant would be inevitable. In this case, the
implant must go underneath the muscle. It cannot be said that one
method is better than the other; the operating surgeon should, based
on his or her experience, decide in each individual case whether the
implant should be placed above or below the muscle.
A submuscular implant is appropriate if the following conditions exist:
)
Glandular hypoplasia, with thin covering of soft tissue
)
Postpartum involution atrophy with moderate surplus of thin soft
tissue
)
Glandular aplasia
)
Previous subcutaneous mastectomy
)
Recurrent capsular fibrosis
)
Pressure atrophy of the breast where an implant is already in place
Submuscular Implant
Preoperative marking of the breast, determining where the new inframammary fold is to be positioned, premedication, and anesthesia all
follow the same procedure with submuscular implants as with supramuscular implants.
As with supramuscular implant positioning, the inframammary access
will be chosen:
1. Following inframammary incision, sharp dissection is carried out as
far as the pectoral fascia. (Fig. 7.22)
2. The pectoralis muscle is detached from its caudal attachment by
means of electrocoagulation. (Fig. 7.23)
298
Fig. 7.22
https://t.me/med1917
7 Breast Surgery
Fig. 7.23
299
7 Breast Surgery
https://t.me/med1917
3. Subsequently, dissection of the implant pocket is continued in a
cranial or craniomedial direction.
Injury to the intercostal space is to be avoid ed under all circumstances
in view of the danger of pneumothorax. Insertion of an illuminated
retractor or endoscope will make dissection easier. (Fig. 7.24)
4. The pectoralis muscle insertion is detached in the medial region in
the region of the sternum; great care should be taken that the two
implant compartments do not connect. Numerous perforating vessels which extend from the intercostal musculature into the pectoralis muscle are electrocoagulated. After the caudal and medial sections of the pectoralis muscle as far as the height of the implant
pocket of the nipple-areola complex (NAC) have been detached, the
cranial section of the implant pocket is dissected. The muscle is
detached sharply as far as the marked horizontal line in the nipple
region. If the muscle is dissected too medially, this can misshape the
implantandthebreastwillnothavemedialdemarcation.The
pocket may not be dissected in the cranial region below the lower
axillary line. (Fig. 7.25)
300
Fig. 7.24
https://t.me/med1917
7 Breast Surgery
Fig. 7.25
301
7 Breast Surgery
https://t.me/med1917
5. Following careful hemostasis, the trial implant is inserted; this
implant should correspond to the anatomical circumstances as well
as to the patient’ s wishes. In order to insert the implants in as careful
a manner as possible, the compartment is held open using a Langenbeck retractor in the cranial region.
It is important that:
– The trial implant should fill the entire com partment, fitting
completely and with no rippling.
– When inserting the implants, it is essential that no sharp instruments
are used.
After removing the trial implant and after further follow-up checks
hemostasis, a 10 Redon suction drain should be inserted, which should
bepositionedatthecaudalpoleoftheimplantpocketanddrainoff
level with the anterior axillary line in the inframammary fold.
The final implant can then be inserted in the usual manner. (Fig. 7.26)
One important aspect of submuscular breast augmentation is the closure of the implant pocket; perforation of the implan t must be avoided
under all circumstances.
If the new inframammary fold needs to be accentuat ed, fixation of the
caudal pole of the implant pocket to the pectoral fascia can be carried
out.
The new inframammary folds are examined for symmetry between the
two sides.
Wound closure (using Monocryl interrupted sutures), wound dressing,
and wound aftercare following the same procedure as already outlined
for the supramuscular access. (Fig. 7.27)
302
Fig. 7.26
https://t.me/med1917
7 Breast Surgery
Fig. 7.27
303
7 Breast Surgery
https://t.me/med1917
Dual Plane Dissection
In the event of moderate ptosis of the breast, ‘ dual plane’ dissection is
recommended. This means that the implant is inserted submuscular in
the cranial region and subglandular in the caudal region. As a result,
suitable movement of the gland over the implant is achieved.
The further course of action is the same as with supram uscular insertion.
The advantages of choosing the submuscular compartment include:
1. No pressure-related disruption of gland vascularization
2. No pressure atrophy of the gland, since the gland can move over the
muscle
3. A natural transition into the neckline
4. Implant rippling is reduced
Figure 7.28 shows the position of the implan t underneath the muscle and
above the muscle, respectively. One can see that, as a result of the traction and fitting of the implant, the muscle retracts after being detached
and this ensures good coverage over two-thirds of the implant.
The three-lay erwound closure is thesame for both accessmethods.
The concealed fixation suture of the muscle fascia with 2.0 Monocryl is
important since this ensures that the inframammary fold is defined and
a stable counter-position to the implant is created.
304
Соседние файлы в папке Библиотека им академика М.И. Перельмана