[Breast reconstruction after mastectomy: necessity, evolution, techniques and research goals]. / Reconstruction mammaire après mastectomie : nécessité, évolution, techniques et objectifs de recherche.

Breast reconstruction is recognized as an integrated part of breast cancer treatment today. Depending on tumor characteristics, different types of partial and total breast resections are indicated: tumorectomy, nipple/skin sparing or complete mastectomy. Patients' desires, general health status and body shape, as well as the necessity of adjuvant therapies, lead to the individual reconstruction plan. Next to implant-based reconstructions, autologous reconstructions play a great role, including local, pedicled and free flaps as well as autologous fat grafting. In cases of tumorectomy, oncoplastic surgery comes into play: it is the combination of a large tumor resection and immediate breast reconstruction with the remaining breast tissue.

À l'heure actuelle, la reconstruction mammaire est reconnue comme partie intégrante du traitement du cancer du sein. En fonction des caractéristiques tumorales, différents types de résections mammaires sont indiqués : tumorectomie, mastectomie avec épargne du mamelon ou de la peau, ou mastectomie totale. L'état de santé général, la nécessité de thérapies adjuvantes, la morphologie et les souhaits des patientes déterminent le plan de reconstruction. En plus de la reconstruction à base d'implants, celle par lambeaux autologues (lambeaux locaux, pédiculés ou libres), ainsi que le transfert de graisse autologue jouent un rôle important. En cas de tumorectomie, la chirurgie oncoplastique entre en jeu, soit la combinaison d'une résection tumorale importante et d'une reconstruction mammaire immédiate par remaniement de la glande persistante.

Improved Adipocyte Viability in Autologous Fat Grafting With Ascorbic Acid-Supplemented Tumescent Solution.

INTRODUCTION: In reconstructive surgery, fat volume augmentation is often necessary for esthetic or functional reasons. As an alternative to synthetic and xenogeneic materials, autologous fat grafting (AFG) based on liposuction is gaining popularity, yet successful transplantation and long-term volume maintenance are difficult. Standard tumescent solution formulations neglect adipocyte and stromal vascular fraction (SVF) cell survival during extraction, as well as SVF differentiation into adipocytes thereafter, all of which are crucial for the success of AFG. Here we hypothesized that addition of ascorbic acid (AA) to the tumescent solution could prevent liposuction-induced cell damage. MATERIALS AND METHODS: The effect of 0.1 mmol/L AA in tumescent solution was investigated in a previously described ex vivo model of AFG. Briefly, excision fat was infiltrated with tumescent solution, with or without AA, and incubated for 20 minutes at 37°C. Hand-assisted liposuction was then performed with a blunt cannula. Total cell viability, clonogenicity, and differentiation capacity of the SVF cells were assessed. RESULTS: With AA, 10.3% more cells and in particular 14.9% more adipocytes survived liposuction. Clonogenicity, adipocyte and osteoblast differentiation by SVF cells remained unchanged. CONCLUSIONS: Addition of AA successfully improved survival of adipocytes during liposuction without affecting SVF growth and differentiation. This study therefore identified a useful supplement to the tumescent solution which may lead to improving AFG success.

Regeneration of nerve crush injury using adipose-derived stem cells: A multimodal comparison.

INTRODUCTION: To restore full function following nerve crush injuries is critical but challenging. In an attempt to develop a viable therapy, we evaluated the effect of rat adipose-derived stem cells (rASC) in 2 different settings of a sciatic crush injury model. METHODS: In the first group, after 14 days of nerve crush injury, rASCs were injected distal to the lesion under ultrasound guidance. In the other group, alleviation of compression through clip removal (CR) was combined with epineural injection of rASCs. Gait analyses, MRI, gastrocnemius muscle weight ratio (MWR), and histomorphometry were performed for outcome analysis. RESULTS: CR combined with rASC injection resulted in less muscle atrophy, as evidenced by MWR. These findings are further supported by better functional and anatomical outcomes. DISCUSSION: Animals treated with CR and epineural stem cell injection showed enhanced anatomical and functional recovery. Muscle Nerve 58: 566-572, 2018.

Epineural adipose-derived stem cell injection in a sciatic rodent model.

BACKGROUND: The aim was to evaluate the regenerative effect of epineural injection of rat ASCs (rASCs) in three different settings of acute and chronic compression in a rat sciatic nerve model. METHODS: Acute compression (60 s) with a vessel clamp over a distance of 1 mm (group 1) or 10 mm (group 2), as well as chronic compression with a permanent remaining, nonabsorbable polymeric clip over a distance of 1 mm (group 3) was performed. Depending on the group, either 5 × 106 rASCs or the same volume (25 µl) of culture medium (CM) was injected with a 30G needle in the epineurium at the time of compression. Outcome measures were functional gait evaluations, imaging analysis, histomorphometric analyses, and muscle weight. RESULTS: The rats in group 2 had a better function than those with group 1 at one and especially at 2 weeks. After 4 weeks however, almost all rats were close to a normal function. There was a similar Muscle Weight Ratio (MWR) after 2 weeks in all groups, whereas after 4 weeks, the MWR in group 3 was lower compared with group 1 and 2. Histomorphometric analysis showed a better myelination in group 1 & 2 compared to group 3 after 4 weeks. ASCs have a beneficial effect on myelin thickness (G-Ratio). CONCLUSIONS: We successfully evaluated the regenerative effect of epineural injection of rASCs in three different settings of acute and chronic compression. However, there were no significant differences in outcomes between the ASC-treated groups and control groups.

Reconstruction of gluteal deformities: a systematic review and experience of four cases.

BACKGROUND: The reconstruction of gluteal deformities remains a major challenge. The aim of this article is to provide a systematic review of the literature concerned, and to present a case series with representative defects from various zones. METHODS: A review of the literature was performed using PubMed, EMBASE, and The Cochrane Library, in accordance with the PRISMA statement. Quality of evidence was rated according to GRADE. Patients with various buttock deformities were included and, depending on the defect, the reconstructive techniques applied consisted of lipoinjection, local fasciocutaneous flap, or pedicled gracilis muscle flap. Complications, patient's pain assessment, impairment in everyday-life activities, aesthetic outcome, objective assessment of sensitivity, and recurrence were considered. RESULTS: A total of 498 records were identified in the literature search. Of those, 12 studies met the PICOS (participants, interventions, comparators, outcomes, and study design) criteria. Overall, 41 patients were analysed, the evidence of which was of low quality. In this study, four patients (three female and one male) with a mean age of 44 ± 15 years were operated on between 2010-2014. The mean operation time was 83 ± 30 minutes. One patient required revision due to persistent seroma and recurrence, and one patient required neurolysis and gracilis denervation due to neuroma and scarring. After a mean follow-up of 40 ± 21 months, the results were functionally and cosmetically satisfactory. CONCLUSIONS: Reconstruction of buttock deformities using an integrated approach can lead to a long-lasting, functionally and aesthetically satisfactory result. However, evidence is limited due to the lack of good-quality studies.

Progenitor cell therapy for sacral pressure sore: a pilot study with a novel human chronic wound model.

INTRODUCTION: Chronic wounds are a major health-care issue, but research is limited by the complexity and heterogeneity in terms of wound etiology as well as patient-related factors. A suitable animal model that replicates the situation in humans is not available. Therefore, the aim of the present work is to present a standardized human wound model and the data of a pilot study of topically applied progenitor cells in a sacral pressure sore. METHODS: Three patients underwent cell harvest from the iliac crest at the time of the initial debridement. Forty-eight hours after bone marrow harvest and debridement, the CD34+ selected cell suspension was injected into the wound. With the aid of a laser scanner, three-dimensional analyses of wound morphometry were performed until the defect was reconstructed with a local flap 3 weeks after debridement. RESULTS: Decreases in volume to 60%±6% of baseline on the sham side and to 52%±3% of baseline on the cell side were measured. Histologic work-up revealed no signs of metaplastic, dysplastic, or neoplastic proliferation/differentiation after progenitor cell treatment. CD34+ cells were detected in the biopsies of day 0. CONCLUSIONS: The pressure sore wound model allows investigation of the initial 3 weeks after cell-based therapy. Objective outcome analysis in terms of wound volume and histology can be performed without, or with, minimal additional morbidity, and the anatomy of the sacral area allows a control and study side in the same patient. Therefore, this model can serve as a standard for wound-healing studies. TRIAL REGISTRATION: ClinicalTrials.gov NCT00535548.

Scar asymmetry after abdominoplasty: the unexpected role of seroma.

Achievement of symmetry remains one of the goals of cosmetic procedures. Interestingly, scar asymmetry after abdominoplasty has been rarely considered a complication. However, this can have a significant impact on patient and surgeon satisfaction. This study identifies silent seromas as a potential cause of scar asymmetry.Among abdominoplasty procedures in a university hospital institution over a 30 months' period (October 1, 2007 to April 1, 2010), we retrospectively identified 6 patients who developed abdominal scar asymmetry only 3 months postoperatively and without any early warning complications (hematoma, seroma, or infection). Clinical examination was completed by abdominal diagnostic ultrasonography. Seroma capsulectomy under local anesthesia was performed in all cases.In all patients clinically presenting late abdominal scar asymmetry, ultrasonography confirmed the presence of an encapsulated chronic seroma. Surgical capsulectomy under local anesthesia resulted in reestablishment of former symmetry and high patient satisfaction. No complications such as wound infection, dehiscence, hematoma, or recurrence of seroma were detected after revision surgery.In our experience, fibrous capsule due to chronic seromas resulted in abdominal scar deviation and asymmetry. Surgical capsulectomy followed by wearing of compressive garments resulted to be an effective treatment with pleasant aesthetic outcome and no seroma recurrence. Silent seromas should be considered as a possible etiologic factor of scar asymmetries appearing during late follow-up after abdominoplasty.

Body taping for contour surgery.

BACKGROUND: Preoperative marking is of primary importance in body contouring and when precise simulation of skin excisions is difficult. Because the "cut as you go" principle can be delicate, especially in patients after massive weight loss, a simple and quick method is needed for preoperative planning. We suggest an approach that helps visualize the optimal skin incision lines and simulates the postoperative result by body taping. METHODS: Twelve patients who underwent abdominal contouring, including classic and vertical abdominoplasties as well as dog ear and scar revision, were prospectively analyzed. The skin to be excised was preoperatively folded, taped, and then marked. The area marked was measured and compared with the actual intraoperatively resected area and the postoperative result was evaluated after 1 year by the patients and three surgeons. RESULTS: With body taping, an 83% congruence between the preoperative planning and the surgery was obtained and only two patients had additional skin resected. No wound dehiscence and flap necrosis occurred and patients as well as surgeons scored the final body contour positively. CONCLUSION: Body taping is a simple, quick, and economic method for planning contour surgery with high accuracy as demonstrated by the low rate of intraoperative changes of the planned resection and low complication rate.

New posterior auricular perichondrial cutaneous graft for stable reconstruction of nasal defects.

The perichondrial cutaneous graft (PCCG), a reliable composite graft that provides stability, is routinely harvested from the anterior conchal bowl. This established PCCG was simplified by using the less conspicuous posterior auricular donor site, which can be closed without the need of cartilage resection for reconstruction with a postauricular interpolated skin island. Patients with basal cell carcinoma of the nose underwent reconstruction of the nose with a PCCG if parts of the tip cartilage or the fibrofatty tissue were resected. The defect surface area was assessed with a template. Follow-up evaluation included assessment of graft survival, donor-site morbidity, nostril stability, and aesthetic outcome. Of the 14 patients included in the study, whose average defect sizes were 2 cm2 (ala) and 2.5 cm2 (tip), 79% showed primary complete healing. Nostril stability was symmetrical 6 months postoperatively, and no contractions or depressed contour had occurred. In one case, a hyperpigmented area resulted in a slightly imperfect color match. All the donor sites healed without deformity or destabilization of the ear. With the use of this new posterior auricular donor site for graft harvest, functional, stable, and aesthetic reconstruction of the nose can be achieved. The graft- and donor-site morbidity rates are very low, and the results are fully satisfying.