Tgp chi THONG TIN YDl/OC Sd 4 nam 2010
- Khoang each tif bd du'di quang vii tdi nep lan vii khoang 5cm
P H A U T H U A T DIEU TRI PHI DAI VU VOI DUONG SEO HINH CHU "T" NGUOC
Nguyen Dinh Minh", Tran Thiet Sdif*, Nguyen Vu Hoang'**
De phau thuat dieu tri thu ggn vij phi dai, hien ed nhieu phu'dng phap, tuy nhien, viec It/a chon phu'dng phap nao toi Wu nhat la tht/c st/can thiet giup eac phau thuat vien de i/ng dung va mang lai hieu qua tham my kha quan.
I . OAT VAN OE
Phi dai vii la benh ly dae truTig bdi tinh trang tang the tfeh ciia vii tren mifc binh thu'dng do su' phat trien ciia tuyen vii kem theo su' tham nhiem to chifc md. Benh ly vii phi dai d nii' gidi ngoai viec gay mat can bang ve tha'm my, cdn la nguyen nhan ciia cac di chifng lau dai nhu' eac chifng dau cd', viing ngi/c va viing xu'dng ddn do sifc nang d bau vii.
Da cd nhieu ky thuat thu gpn vu du'dc ra ddi vdi nhieu each thiet ke du'dng rach da khac nhau, tuy nhien, cac ky thuat dieu tri vdi du'dng rach da hinh chif T ngu'pc van la nhu'ng ky thuat ed ban, de ifng dung va mang lai hieu qua cao trong tao hinh hinh the vii.
I I . MOT SO DAC DIEM G I A I PHAU HINH THE CUA VU
1. The tich vd
The ti'ch bau vii d phu nif tru'dng thanh trung binh tif 250-300ml. Trong benh ly vii phi dai, the tich vii cd the tang den tren 1500ml trong cac tru'dng hdp vii phi dai khd'ng Id.
Bang 1: Phan loai benh ly vu phi dai Phan loai
Nhe Vifa Nhieu Rat nhieu Khdng lo
The tich vu (ml) 400-600 600-800 800-1000 1000-1500
>1500
Khdi lu'ang vu u'dc tinh lay bd (gr)
100-300 300-500 500-800 800-1300
>1300 2. Dae diem vu binh thu'dng
DPdng kinh ly tu'dng ciia ddn vj quang num vii la 35-40mm d nif gidi tru'dng thanh, vj tri ciia quang niim vii binh thu'dng va trong thiet ke phau thuat dPdc xac dinh nhu' sau (hinh 1):
- Khoang each tif ci/c tren quang vu tdi hdm ifc la 17cm
- Khoang each tif bd trong quang vii tdi dPdng giifa la 9,5cm
Hinh 1: \/i tri eua quang num vu binh thu'dng I I I . CAC P H U a N G PHAP PHAU THUAT
Cd hai loai phau thuat, cd ban di/a tren sy' can thiep vao ddn vi quang num vii: thu gpn vu cd ghep quang vii va thu gpn vii khdng ghep quang vu.
1. Chuan bi tru'dc md
Trong hau het cac ky thuat, ngu'di ta sif dung mau thiet ke ciia Wise va phu'dng phap xae djnh du'dng rach da ciia Bisenberger giup ddn gian hda khau thiet ke.
Tru'dc tien, eu'e tren ciia phife hdp quang niim vii mdi du'dc xac bang each do 17cm tif hdm ifc theo du'dng keo tif hdm ifc tdi niim vu. Ci/c trong ciia phife hdp quang num vu mdi du'dc danh dau each du'dng giifa 9-lOem.
Chu vi ciia vdng trdn quanh phife hdp quang niim vu khoang 14cm de tranh tinh trang co keo khi quang vii du'dc thiet ke cd dPdng kfnh 4cm. Du'dng rach da md rdng d 2 ben cd chieu dai la 5cm, tu'dng ifng vdi cPc du'di ciia vu sau khi tao hinh.
'ThS,, " " T h S . , Benh vien Xanh-Pon Ha N o i , " PGS.,TS., Tru'dng OH Y Ha Noi.
Tgp chi THONG TIN YDl/OC Sd 4 ndm 2010
Hlnh 2 fa, b): Mau thiet ke du'dng khau da ehO' T eua Wise
Od md rdng ciia du'dng thiet ke nay phu thudc vao khdi Itfdng tuyen vii can lay bd va mifc dp thifa da. Oe ddn gian hda, Biesenberger danh dau hai du'dng rach bang thao tac day toan bp tuyen vii len tren vao trong va len tren ra phfa ngoai giiip u'dc lu'dng phan tuyen va da can lay bd. Thao tac nay du'dc sif dung rdng rai va mang lai hieu qua tha'm my eao trong tao hinh dp nhd cho bau vii.
2. Ky thuat thu ggn vu cd chuyen ghep ddn vj quang num vii (Thorek)
Toan bd ddn vj quang niim vu du'dc lay ra nhu' manh ghep da day vdi du'dng kfnh 4-5cm. Thiet ke diem A la vj tri mdi ciia niim vu (19cm tif hdm ifc), B la diem gitfa ciia nep lan du'di vii, C va D' la hai dau tan ciia nep lan du'di vii, hai diem C, D du'dc danh dau each A khoang 8 cm sao cho C'CH-DD'=C'D'. Rach da va lay bd da, tuyen vu theo 2 phan kieu miii cam dpc va ngang (AB va C'DO. Bau vii du'dc tao hinh lai bang each khau C, 0 va B (hinh 3).
C D
Hlnh 3: Ky thuat thu ggn vu Thorek
Tai vj trf A (dinh ciia bau vii mdi), rach da vdng trdn cd tam diem la A vdi kfch thu'dc diing bang ddn vj quang niim vti va lay bd thu'dng bi. Sau dd, ddn vj quang niim vu du'dc ghep lai tren vi trf mdi va dat gdi gac trong vdng 6 ngay.
3. Ky thuat thu ggn vu khdng ghep quang mim vii
Ddn vj quang niim vii se du'dc cap mau bang mdt vat to chifc tai chd. Nhifhg thay dd'i ky thuat chii yeu du^ vao viec thay dd'i kieu vat nudi quang num vu: cap mau cho vat bdi phan tuyen du'di vat, hay cap mau bdi da xung quanh ddn vj quang niim vii.
Tgp chi THONG TIN YDl/OC Sd 4 ndm 2010
3.1. Ky thuat thu gon vu cudng tren va cat tuyen theo hlnh chem (Pitanguy)
Hlnh 4: Ky thuat cat tuyen hinh chem eua Pitanguy
Dung md hinh eiia Wise trong thiet ke tru'dc md' khi BN trong tu' the ngdi hoac difng.
Rach da quanh quang niim vii du'dng kfnh 40-45mm, phan cudng tren du'dc thiet ke tif dinh cao nhat ciia vdng trdn quanh quang vii mdi tdi du'di eu'e du'di eiia ddn vj quang niim vii it nhat 2cm. Cat bd tuyen d ci/c du'di vii va phfa dtfdi cudng theo hu'dng chech len tren ra sau tdi tan cd ngtfc ldn theo dang hinh chem, day quay xudng du'di va dinh quay len tren.
3.2. Ky thuat thu ggn vu cuong du'di (RIbeIro)
Viec bao tdn hai tru da-tuyen d hai ben cudng lam tang kha nang cap mau cho ddn vj quang num vii. Op nhd ciia tuyen vii dtfdc tai tao lai nhd viec khau lai hai cdt tru tuyen d hai ben bang chi Vicyl 2.0.
Day tru'dt cudng nudi mang quang niim vii len tren va cd djnh A-A'. Khau lai cac diem B-B' va C-E-C. Khau da chi ludn hoac khau vat. Dat dan Itfu ap lu'c am 48h kem bang djnh hinh tuyen vii kieu sd 8.
Ngudn cung cap mau va cam giac eho phife hdp quang niim vii trong ky thuat nay la cac maeh xuyen xuat phat tif ddng mach lien su'dn tru'dc sd 4-5 va cae nhanh chi phdi da ciia than kinh lien su'dn.
Thiet ke tru'dc phau thuat sif dung mau thiet ke theo Wise nhu' cac phu'dng phap khac, trong ky thuat nay, mau thiet ke cd the hdi nga nhe ve phia ngoai khoang 30° de gii/ lai nhieu hdn to chifc d gde phan tu" du'di ngoai, giup tang kha nang phue hdi cam giac cho ddn vj quang niim vu. Cudng dtfdi du'dc thiet ke cd chieu rdng tif 8-lOcm.
Hlnh 5: Ky thuat thu ggn vu cuong du'di eua RIbeIro
Rach da vdng quanh quang niim vii vdi du'dng kfnh 40-45mm. Lay bd thu'dng bi viing cudng, eat bd tuyen xung quanh cudng theo dang hinh mdng ngu'a, bao tdn mdt Idp to chifc tru'dc mac ed ngu'c ldn ndi chifa cae mach nudi vat. Tach rdi cudng du'di khdi thanh ngu'c nhu'ng giif lai lien ket d khoang lien su'dn 4-5. Cudng vat cd chieu day 2cm d du'di quang vii va day den 8cm tai gde vat. Cudng mang tuyen va quang niim vii du'dc cd djnh vao mat tru'dc ed ngu'c ldn de tranh sa tre thif phat.
Ddng da thu'c hien nhu' eae ky thuat khac.
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Tgp chi THONG TIN Y Dl/OC Sd 4 ndm 2010
3.3. Ky thuat thu ggn vu cuong dgc kep (Mc Kissoek)
Vung da, tuyen can cat bo
Hlnh 6: Ky thuat thu gon vu cuong doe kep eua Me KIsoek
Nguyen ly cd ban ciia ky thuat dd la thiet ke vat da tuyen mang ddn vi quang niim vii bao gdm ca cudng tren (cudng da-md) va cudng du'di (cuong da-tuyen) nham tang kha nang cap mau cho ddn vj quang niim vii.
Thiet ke theo mau ciia Wise, tuy nhien, phan cudng kep dpc du'dc thiet ke dpc tif dinh vi tri mdi ciia quang num vu den tan nep lan du'di vii. Be rdng eiia cudng tif 4-6cm. Rach da quanh quang niim vu vdi du'dng kfnh 40- 45mm. Lay bd thu'dng bi viing cudng nudi, eat bd da va tuyen theo 3 ddn vj: ddn vi da tuyen phfa trong va ngoai, ddn vj tuyen phfa sau quang vu. Vat da tuyen cdn lai d 2 ben phai cd dp day l-2cm de dam bao nudi du'dng. Phan cudng du'di cd dp day 8cm, tu'dng ty' ky thuat cudng du'di, phan cudng tren cd dp day khoang l-2cm, dii mdng giiip eho viec gap gde cudng tren di chuyen ddn vj quang num vii len tren du'dc de dang hdn.
I V . BAN LUAN
Ngay nay, cd rat nhieu phu'dng phap phau thuat dieu trj thu gpn vu phi dai vdi eac du'dng khau da quanh quang vii (round block), du'dng khau dpc hay hinh chif J, eac dtfdng khau nay ddi hdi phau thuat vien can ed rat nhieu kinh nghiem khi cat bd va tai tao lai tuyen vii. Viec cat bd md tuyen va du'dng rach da khdng triing khdp vdi nhau, do dd, ngu'di lam phau
thuat can cd si/ djnh hinh rat tdt ve khdng gian 3 chieu. Hdn nu'a, eac du'dng khau vdng quanh quang num vu hoac dtfdng khau dpc ludn tao ra cac nep nhan da trong thdi gian dau, nen gay ra chut ft thac mac cho BN trong thdi gian nay. Tuy nhien, vdi mau thiet ke ciia Wise, nhd phtfdng phap do dae ehfnh xae, du'dng eat da triing vdi lat cat ciia md tuyen, do vay viec thu'c hien ky thuat cd phan ddn gian va de mang lai hinh the dep cho bau vu, cung nhu"
rut ngan thdi gian phau thuat nhd khau chua'n bj. Nhu'pc diem duy nhat ciia du'dng rach da nay la de lai seo dai chiem toan bd nep lan du'di vii.
Ndi chung, ky thuat thu gpn vu cd chuyen ghep quang num vu du'dc chi djnh tuyet ddi cho cac trtfdng hdp vu phi dai khd'ng Id, vii sa tre nhieu vdi chieu dai doan hdm ifc den quang vu (doan 1) tren 30cm hoac cac BN ed benh ly mach mau, da cd can thiep tai quang vii tif trtfdc hay sau dieu tri khdi u vii khac.
Tuy nhien, nhu'pc diem cua ky thuat dd la kha nang hoai tif ddn vj quang num vii sau ghep, mat cam giac ciia dau vii va hdi thieu chieu eao eiia bau vii do cat md tuyen d trung tam.
Oe khac phue nhu'dc diem nay, mdt sd tac gia hoac khdng eat bd gde tam giac tuyen phia tren hoac de lai dao tuyen phfa ci/c du'di de lam tang dp nhd cho dinh ban cau.
Tgp chi THONG TIN Y Dl/OC Sd 4 nam 2010
Ky thuat tao hinh thu gpn bang cudng du'di va cudng dpc kep du'dc chi dinh cho cae BN ed the tich vu phi dai d mifc nhieu hoac rat nhieu.
Tuy nhien, cd mpt sd tac gia cd the ehi djnh cho cac vii phi dai khd'ng Id nhu'ng dp dai doan 1 khdng hdn 40cm de dam bao an toan cap mau cho ddn vj quang niim vii. LTu diem chinh ciia hai phu'dng phap nay la tao du'dc dp nhd cho bau vii va dae biet la ky thuat cudng dpc kep dam bao kha nang cap mau rat tdt cho ddn vj quang niim vii. Hdn nifa, nhd viec bao tdn cac nhanh mach lien su'dn di kem than kinh nen quang num vii sdm phue hdi cam giac hdn cac ky thuat khac. Nhu'dc diem chi'nh eiia ky thuat la theo thdi gian se xuat hien tinh trang sa tre thif phat ciia md tuyen, dan tdi khoang each quang vu-nep lan du'di vu (doan 3) tang nhanh trong nam dau tien. Oe khac phue nhu'dc diem tren, ngu'di ta khuyen cao thiet ke doan 3 khdng qua 5cm (se tang thanh 7cm sau nam dau) va cd djnh that tdt cudng tuyen vao mac cd ngu'c ldn d phfa tren.
Ky thuat tao hinh theo Pitanguy khdng chi giif lai cudng tren ma ddn vi quang niim vii cdn du'dc cap mau bdi 2 cudng da-md d hai ben (trong-ngoai). Hdn ntfa, nam trong ranh gidi eiia Idp vd da-md va tuyen phfa sau la eac nhanh than kinh ehi phdi cam giac cho quang niim vii (nhanh than kinh lien su'dn 4 phia ngoai). Viec cd djnh phan tuyen cdn lai nhd cudng da-md d hai ben va cudng tren d gitfa giiip cho tuyen vii rat it cd nguy ed bj sa tre thif phat. Nhu'dc diem duy nhat ciia ky thuat do la
viec di chuyen han che eiia ddn vj quang niim vii tdi vj tri mdi, vi vay ky thuat du'dc chi djnh eho cae BN phi dai vii nhe hoac vifa.
V. KET LUAN
Tao hinh thu gpn vii phi dai vdi du'dng seo hinh chCf T ngu'pc la lu'a chpn dau tay eho cac phau thuat vien tao hinh trong giai doan dau dieu tri phau thuat benh ly nay do kha nang chi'nh xac cao, chii ddng trong thiet ke va mang lai hieu qua tha'm my kha quan trong tai tao lai hinh the bau vu.
Vdi mau thiet ke ciia Wise, chiing ta cd nhieu li/a chpn ve ky thuat khac nhau tiiy thudc vao mifc dp phi dai, dp sa tre eiia vii, tinh trang phau thuat toan than, tai eho ciia BN va kinh nghiem ciia tifng phau thuat vien.
T A I LIEU THAM KHAO
1. Moray P., Chavoln J.P.: Chirurgie plastique du sein. Paris, Elsevier, 2003.
2. Laladrle J.P., Jouglard P.: Chirurgie plastique du sein. Paris, Masson, 1974.
3. McKlssock P.K.: Reduction mammaplasty with a vertical dermal flap. Plast Reconstr Surg, 1972, 49(3), pp.245-252
4. Pitanguy I.: Une nouvelle technique de plastie mammaire. Etude de 245 cas consecutifs et presentation d'une technique personnelle. Ann Chir Plast, 1962, 7, pp. 199-208.
5. Revo! M., Servant J.M.: Manuel de chirugie plastique reconstructrice et reparatrice. Paris, Editions Pradel, 1993.
6. RIbeIro L.: A new technique for reduction mammaplasty. Plast Reconstr Surg, 1975, 55(3), pp.330-334.
1. Thorek M.: Twenty five years experience with plastic reconsytruction of the breast ant transplantation of the nipple. The American Journal Of Surger/, 1945, 67(3), pp.445-458.S'
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