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INTRODUCTION: Local anesthetics with adrenaline are widely used in routine practice and have long proven their benefits and safety. The rare complications due to their use mainly concern immuno-allergic and vascular mechanisms. DESCRIPTION: In this article, we present four similar cases of early transfixing skin necrosis occurring after radioguided breast biopsy under local anesthesia using epinephrine local anesthetics in the context of a diagnostic approach to breast cancer. DISCUSSION: Although the literature is comforting about the use of local anesthetics, even on the extremities, severe skin complications continue to be reported sporadically. The analysis and understanding of these phenomena would allow, in the long run, to avoid them and to reduce their importance. CONCLUSION: The occurrence of skin necrosis after breast biopsy under radiographic control is rare and seems to be related to the local anesthetic procedure. Although similar cases have been reported in the literature, it does not seem possible today to conclude on the exact physiopathology of these complications. A better knowledge of the pathophysiology of these complications would help to avoid their occurrence in the future.
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Anestesia Local , Anestésicos Locais , Humanos , Anestesia Local/efeitos adversos , Anestesia Local/métodos , Anestésicos Locais/efeitos adversos , Mama/cirurgia , Epinefrina/efeitos adversos , Biópsia , NecroseRESUMO
BACKGROUND: The aim of the study is to evaluate functional and oncological outcomes of patients undergoing abdominal wall soft tissue tumors (AWSTT) surgery. METHODS: All consecutive patients that underwent surgery for malignant and intermediate AWSTT from 1999 to 2019 were retrospectively analyzed. RESULTS: Ninety-two patients were identified, 20 (22%) operated on for a desmoid tumor and 72 (78%) for a soft tissue sarcoma (STS). Fifty-two patients (57%) had in toto resection of the abdominal wall (from the skin to the peritoneum) and 9 (10%) required simultaneous visceral resection. The closure was direct in 28 patients (30%) and requiring a mesh, a flap or a combination of the two in respectively 42, 16, and 6 patients (47%, 17%, 6%). The postoperative complications rate was 26%. Thirteen patients (14%) developed an incisional hernia after a median delay of 27 months. After a median follow-up of 40 months, out of the 72 patients operated on for STS, 7 (10%) developed local recurrence and 11 (15%) distant recurrence. The median recurrence-free and overall survivals were 61 and 116, months respectively. CONCLUSIONS: Management of AWSTT requires extensive surgery but allows good local control with an acceptable rate of incisional hernia.
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Neoplasias Abdominais/cirurgia , Hospitais com Alto Volume de Atendimentos/estatística & dados numéricos , Recidiva Local de Neoplasia/cirurgia , Procedimentos de Cirurgia Plástica/mortalidade , Sarcoma/cirurgia , Neoplasias Abdominais/patologia , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Feminino , Seguimentos , Humanos , Masculino , Pessoa de Meia-Idade , Recidiva Local de Neoplasia/patologia , Prognóstico , Estudos Retrospectivos , Sarcoma/patologia , Taxa de Sobrevida , Adulto JovemRESUMO
Bachground: Robotic breast surgery is an emergent procedure with encouraging preliminary results. The aim of this study is to assess the feasibility and the safety of robotic nipple sparing mastectomy (RNSM) with immediate prosthetic breast reconstruction (IPBR). Methods: This is a prospective study including from December 2015 to January 2020 all RNSM surgeries with IPBR, in patients with moderate ptosis and A B or C cup. The primary endpoint was the rate of major necrosis. Secondary endpoints were conversion rate, postoperative complications (infections, hematoma, implant exposure), aesthetic results and quality of life. Results: 79 patients underwent 138 RNSM with IPBR. The average follow-up was 28 months. 2 procedures required conversion. Two cases of major necrosis occurred (1.4%). 9 surgical site infections were observed (6.5%), 4 infections could be treated with implant replacement. Unfortunately, 5 others resulted in implant loss. 4 other implant losses occurred: 2 due to major necrosis, and 2 due to periprosthetic capsula. In total, 9 implants were lost (6.5%). Esthetical results were mostly very satisfying and quality of life was not affected by the mastectomy. Conclusions: RSNM with IPBR was associated with low rates of major necrosis. It is a safe and reproducible procedure that allows breast reconstruction without visible scar.
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Neoplasias da Mama , Mamoplastia , Procedimentos Cirúrgicos Robóticos , Neoplasias da Mama/cirurgia , Humanos , Mastectomia , Mamilos/cirurgia , Estudos Prospectivos , Qualidade de Vida , Procedimentos Cirúrgicos Robóticos/efeitos adversos , Resultado do TratamentoRESUMO
Breast cancer is one of the most commonly diagnosed malignancies in women of childbearing age. One of the surgeries performed in the management of the disease is mastectomy , which might negatively affect body image and quality of life, and breast reconstruction is seen as a remedy to this problem. However, for the women who are interested in having children after treatment of breast cancer, the debate is whether they can have a successful pregnancy and delivery after breast reconstruction.
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Neoplasias da Mama/cirurgia , Mamoplastia , Gravidez/fisiologia , Criança , Feminino , Humanos , Mastectomia , Resultado da Gravidez , Qualidade de VidaRESUMO
BACKGROUND: Robotic nipple-sparing mastectomy (RNSM) could be a significant advancement in the treatment of breast cancers and prophylaxis because the mastectomy is performed without leaving any scar on the breast. The aim of this study was to assess the feasibility and the safety of RNSM with immediate prosthetic breast reconstruction (IPBR). METHODS: In this prospective study, RNSM with IPBR was offered to patients with breast cup size A, B or C and ptosis grade ≤ 2. In case of oncologic surgery, RNSM was proposed only if the tumor was located more than 2 cm away from the nipple-areola complex (NAC) and if postoperative radiation was not indicated. In case of prophylactic surgery, RNSM was proposed only if a high-risk genetic mutation had been identified. The primary endpoint was the rate of skin or NAC necrosis. The rate of conversion to open technique, the duration of the procedure, and postoperative complications were also analyzed. RESULTS: Sixty-three RNSM with IPBR were performed in 33 patients. There were no cases of mastectomy skin flap or NAC necrosis. We had to convert to an open technique in one case (1.6%). Three infections occurred (4.8%), one leading to implant loss (1.6%). No other major complications were observed. CONCLUSIONS: Preliminary data attest to the feasibility, the reproducibility, and the safety of this approach. However, long-term data are needed to confirm the oncological safety and the esthetic stability of the result. Trial registration identifier NCT02673268.
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Mamoplastia/métodos , Mamilos/patologia , Mastectomia Profilática/métodos , Procedimentos Cirúrgicos Robóticos/métodos , Adulto , Conversão para Cirurgia Aberta , Estudos de Viabilidade , Feminino , Humanos , Infecções/etiologia , Mamoplastia/efeitos adversos , Pessoa de Meia-Idade , Necrose/etiologia , Mamilos/cirurgia , Tratamentos com Preservação do Órgão/efeitos adversos , Tratamentos com Preservação do Órgão/métodos , Complicações Pós-Operatórias/etiologia , Complicações Pós-Operatórias/cirurgia , Mastectomia Profilática/efeitos adversos , Estudos Prospectivos , Procedimentos Cirúrgicos Robóticos/efeitos adversos , Retalhos Cirúrgicos/efeitos adversos , Fatores de Tempo , Adulto JovemRESUMO
Nipple-sparing mastectomy (NSM) is increasingly popular for the treatment of selected breast cancers and prophylactic mastectomy. Surgical scarring and esthetic outcomes are important patient-related cosmetic considerations. Today, the concept of minimally invasive surgery has become popular, especially using robotic surgery. The authors report the first case of NSM using the latest version of the da Vinci Xi surgical system (Xi). The final incision used to remove the entire mammary gland was located behind the axillary line. In this position, hidden by the arm of the patient, the incision was not visible and was compatible with immediate breast reconstruction.
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Mastectomia Subcutânea/métodos , Procedimentos Cirúrgicos Robóticos/métodos , Neoplasias da Mama/prevenção & controle , Feminino , Humanos , Mastectomia Subcutânea/instrumentação , Pessoa de Meia-Idade , Mamilos , Mastectomia Profilática/métodos , Procedimentos Cirúrgicos Robóticos/instrumentaçãoRESUMO
We compared the performance of near-infrared imaging using indocyanine green (ICG) with the radioisotope (ISO) method to detect sentinel lymph nodes (SLNs) in breast cancer, to analyze predictive factors for negative ICG identification. The study included 122 patients who underwent sentinel lymph node biopsy (SLNB) using the combined ISO and ICG technique for primary breast cancer. We assessed the putative association between pathologic/clinical variables and ICG failure to detect SLNs. The ISO identification rate was 96.7% and ICG identification 81.9%. Overweight patients or presence of macrometastasis in SLNB were associated with the risk of ICG failing to detect SLNs (P = 0.02).
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Neoplasias da Mama/patologia , Metástase Linfática/diagnóstico por imagem , Linfonodo Sentinela/diagnóstico por imagem , Espectroscopia de Luz Próxima ao Infravermelho/métodos , Adulto , Idoso , Idoso de 80 Anos ou mais , Axila/patologia , Meios de Contraste , Feminino , Humanos , Verde de Indocianina , Metástase Linfática/patologia , Pessoa de Meia-Idade , Sobrepeso , Linfonodo Sentinela/patologia , Biópsia de Linfonodo Sentinela/métodosRESUMO
BACKGROUND: Nipple-sparing mastectomy (NSM) is increasingly popular for the treatment of select breast cancers and prophylactic mastectomy. This study aimed to analyze the authors' 11-year experience with NSM and breast reconstruction in cases of ductal carcinoma in situ (DCIS) with an emphasis on indications, complications, and cancer recurrence rate. METHODS: Between January 2000 and December 2010, 41 NSMs were performed in 41 women for DCIS. The mean age of the women was 49.7±8.7 years (range, 33-66 years). The indications for NSM were tumor size greater than 3 cm (18 cases), multifocal tumor (16 cases), and tumor recurrence (7 cases). In all cases, the tumor was located more than 2 cm from the nipple-areola complex (NAC), as shown by preoperative radiologic imaging. Histologic results, secondary NAC resection, complications, and cancer recurrence rates were recorded. RESULTS: The NAC was lost in seven cases (17%) due to postoperative necrosis. In another 10 patients (25%), the NAC was secondarily removed due to proximity of the tumor to the resection margin. Five patients were lost to follow-up evaluation (12%). The authors report the long-term follow-up data for the remaining 19 patients (46%). In this group, they observed one local recurrence (5.3%) and one case of ovarian cancer. CONCLUSION: Despite the low locoregional recurrence rate for DCIS, NSM remains controversial because of the nipple necrosis observed and the irradical tumor excisions. Given the ethical impossibility of conducting randomized controlled studies to compare NSM with conventional or skin-sparing mastectomy in DCIS, only long-term follow-up evaluations can demonstrate the safety of NSM. LEVEL OF EVIDENCE IV: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .
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Neoplasias da Mama/cirurgia , Carcinoma Intraductal não Infiltrante/cirurgia , Mamoplastia/métodos , Mastectomia Subcutânea/métodos , Mamilos/patologia , Adulto , Idoso , Biópsia por Agulha , Neoplasias da Mama/patologia , Carcinoma Intraductal não Infiltrante/patologia , Estudos de Coortes , Terapia Combinada , Feminino , Seguimentos , França , Humanos , Imuno-Histoquímica , Mamoplastia/efeitos adversos , Mastectomia Subcutânea/efeitos adversos , Pessoa de Meia-Idade , Necrose/etiologia , Necrose/patologia , Invasividade Neoplásica/patologia , Recidiva Local de Neoplasia/patologia , Recidiva Local de Neoplasia/cirurgia , Estadiamento de Neoplasias , Complicações Pós-Operatórias/fisiopatologia , Estudos Retrospectivos , Medição de Risco , Fatores de Tempo , Resultado do TratamentoRESUMO
Objective: To evaluate outcomes of surgical repair of postesophagectomy neoesophagus-airway fistulas (NEAFs). Methods: We retrospectively included consecutive patients with NEAF managed by various techniques at our center between August 2009 and July 2021. Result: Of the 11 patients (median age, 60 years; interquartile range, 58, 62), 4 had received induction chemoradiotherapy and 4 others induction chemotherapy. NEAF was mainly a complication of anastomotic leakage (n = 6) or attempted stenosis treatment (n = 3). The airway mainly involved was the trachea (n = 8). Airway defects were repaired by resection-anastomosis (n = 5), perforator flaps (n = 4), pedicled pericardium (n = 1), and/or direct suturing (n = 2). Gastric conduit defects were repaired by perforator flaps (n = 6), direct suturing (n = 2), or pedicled pericardium (n = 1). Of the 7 perforator flaps, 4 were internal mammary-artery, two dorsal intercostal-artery, and one supraclavicular-artery flaps. After a median follow-up of 100 months, 2 patients died on early postoperative course from NEAF repair failure and 3 from late NEAF recurrence at 4, 11, and 33 months. Among the remaining 6 patients, 1 died from local tumoral recurrence at 13 months, 1 was last on follow-up at 27 months, alive and eating normally. The other 4 were free from NEAF recurrence and dysphagia or swallowing disorder at 50 months' follow-up. These 4 results were obtained thanks to perforator flap interposition and airway resection anastomosis. Conclusions: Surgical NEAF repair using perforator flap interposition may provide satisfactory long-term function after strong prehabilitation.
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BACKGROUND: Our aim was to report the long-term outcomes of mandibular reconstruction using CAD-CAM-designed 3D-printed porous titanium implants in patients not amenable to a free vascularized fibula flap reconstruction. METHODS: The implants were designed with ProPlan CMF® 2.2 software and manufactured with a Selective Laser Melting (SLM) "layer-by-layer" 3D-printing of pure porous titanium powder beds. Primary endpoints were implant exposure and implant removal calculated using Gray's tests. Secondary endpoints were predictive factors of implant exposure and implant removal, and rates of dental rehabilitation. RESULTS: Thirty-six patients were operated between 2015 and 2017 and were included in this study. Reconstruction using a porous titanium 3D-printed implant was proposed due to medical contraindication for a fibula free flap (n = 13), due to the failure of a previous fibula free flap reconstruction (n = 7), or due to refusal of a fibula free flap reconstruction by the patient (n = 16). The medical indications for mandibular reconstruction were a primary tumor requiring mandibulectomy in nine patients, mandibular osteoradionecrosis requiring mandibulectomy in nineteen patients, and secondary reconstruction in eight patients. The 2-year rates of implant exposure and implant removal were 69.4% and 52.8%. Reconstruction of the symphysis was a high-risk exposure variable (OR 30; p = 0.0003). Only one patient underwent a successful dental rehabilitation. CONCLUSION: The use of a porous titanium 3D- implant for mandibular reconstruction in head and neck cancer patients resulted in high rates of implant exposure and of implant removal, notably when symphysis involvement.
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Implantes Dentários , Reconstrução Mandibular , Humanos , Reconstrução Mandibular/métodos , Titânio , Porosidade , Transplante Ósseo/métodosRESUMO
OBJECTIVE: Tracheobronchial adenoid cystic carcinoma is a rare, slow-growing malignancy with a considerable propensity for local extension that may require complex airway resection to achieve tumor-free margins. The objective of this study was to assess whether our experience supports complex airway resection for tracheobronchial adenoid cystic carcinoma. METHODS: Consecutive patients who underwent curative resection for tracheobronchial adenoid cystic carcinoma at our institution between 1970 and 2019 were included retrospectively and classified as having had complex or standard resection. Complex surgery included total tracheal replacement, associated esophageal resection, pneumonectomy, total laryngectomy with tracheal resection, and carinal resection. Standard surgery included tracheal resection, bronchoplastic resection, lobectomy, and bilobectomy. We obtained data from medical records, referring physicians, patients, relatives, and public death records. RESULTS: Of 59 included patients, 38 had complex and 21 had standard surgery. All 4 (6.8%) patients who died postoperatively had undergone complex surgery. Postoperative morbidity was 32.2% overall and was significantly higher after complex surgery (P = .043). Overall 5- and 10-year survival rates were 81.5% and 60.2%, with no significant differences between groups (P = .31). By univariate analysis, T4 tumor and microscopically detectable tumor in the operative specimen margins and gross tumor in the operative specimen margins were associated with poorer survival (P < .05). In the subgroup with microscopically detectable tumor resection, survival was significantly better with adjuvant radiotherapy (P < .05). CONCLUSIONS: Complex resection for extended tracheobronchial adenoid cystic carcinoma may achieve local control and satisfying long-term survival. However, this demanding procedure is associated with high postoperative morbidity and mortality rates. Because adjuvant radiotherapy improved outcomes after resection resulting in microscopically detectable tumor in the operative specimen margins, expected outcomes after resection with no detectable tumor in the margins must be compared to those after resection resulting in microscopically detectable tumor in the margins plus radiotherapy, according to the operative risk.
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Carcinoma Adenoide Cístico , Procedimentos Cirúrgicos Torácicos , Neoplasias da Traqueia , Humanos , Estudos Retrospectivos , Carcinoma Adenoide Cístico/cirurgia , Carcinoma Adenoide Cístico/patologia , Seguimentos , Neoplasias da Traqueia/patologia , Procedimentos Cirúrgicos Torácicos/métodosRESUMO
INTRODUCTION: Subcricoid-hemilaryngopharyngectomy (SCHLP) with a reconstruction using a fasciocutaneous free flap armed with cartilage graft (FFACG) aims to avoid permanent tracheostomy while still maintaining the laryngopharyngeal functions. The purpose of this study is to report the outcome of this surgical approach. MATERIALS AND METHODS: Retrospective study including 17 men operated between 2001 and 2019. Specific survival rate included death caused by cancer or SCHLP complications. Complications, functional and oncological outcomes were evaluated retrospectively. RESULTS: There were no locoregional recurrences. One patient died due to inhalation pneumonia 3 years after surgery. Tracheostomy was closed in 13 patients (76.5%). Mean decannulation time was at six [1-14] months after surgery. CONCLUSION: SCHPL with FFACG could avoid total pharyngolaryngectomy with good oncologic results. However, tracheotomy is extended and deglutition recovery is long with high risk of aspirations. These complications justify that such surgery should be realized only on selected patients by experienced surgical teams. Expertise of the surgical team is critical.
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Retalhos de Tecido Biológico , Masculino , Humanos , Estudos Retrospectivos , Resultado do Tratamento , Laringectomia/métodos , CartilagemRESUMO
Nasal reconstruction for total rhinectomy is challenging, especially if locoregional flaps are unavailable. Herein, we report the case of a nasal reconstruction combining a forearm free flap as "vascular bridge" and a Delto-Acromial Artery Perforator (DAAP) flap in its free form. The forearm free flap was used to restore missing elements of the nasal lining while the distal part of the radial pedicle has served as a donor vessel for the DAAP free flap which restores the nasal covering. A chondrocostal graft was used as a nasal framework. The nasal aspect at 24 months postop support the patient's satisfaction. The main advantages of the DAAP Flap are the pliability, relative hairless nature, skin thinness and its geographical proximity with the nose avoiding major dyschromia. Moreover, the anatomy consistency makes it easier to harvest, the underlying muscles are respected, and it allows for tension free primary closure without shoulder movement limitation.
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Retalhos de Tecido Biológico , Retalho Perfurante , Procedimentos de Cirurgia Plástica , Artérias/cirurgia , Antebraço/irrigação sanguínea , Antebraço/cirurgia , Retalhos de Tecido Biológico/transplante , Humanos , Retalho Perfurante/irrigação sanguínea , Retalho Perfurante/cirurgia , Procedimentos de Cirurgia Plástica/métodosRESUMO
Objectives: En-bloc complete resection remains the treatment of choice for localized chest wall (CW) tumors. Titanium bars reconstruction demonstrated encouraging results with satisfactory early outcomes. However, long-term outcomes remain under-reported. The purpose of this study is to evaluate long-term outcomes after CW resection and repair with titanium devices. Methods: From June 2012 to December 2018, we retrospectively reviewed all patients with CW tumors who underwent surgical resection and repair using titanium. Long-term outcomes were assessed. Results: We identified 87 patients who underwent CW tumor resections and titanium reconstruction. Sixty-eight patients were included in the study (excluding benign tumors, Pancoast tumors, palliative surgeries, or clavicle reconstruction). There were 29 sarcomas, 20 isolated CW metastases, eight lung cancers, four breast cancers, three thymic malignancies, two sarcomatoid mesothelioma, and one desmoid tumor. Complete resection was achieved in 64 patients (94%), while R1 resection in four patients (6%). Resection involved one rib in two patients, two ribs in thirteen, three ribs in eighteen, four ribs in nine, five ribs in two, seven ribs in one, partial sternum in fifteen, and full sternum in sixteen patients. No patient experienced flail chest. The 1-year, 3-year, and 5-year overall survival rates and disease-free survivals were 82.3%, 61.4%,57.3%, and 67.6%,57.3%,52.6%, respectively. Surgical site infection occurred in 18% (n = 12) of cases. Eleven of twelve patients had an early infection (<1 year), which required material removal in six patients. Asymptomatic connector unsealing occurred in 6% (n = 4), with only one re-intervention. Titanium allergy has never been reported. Chronic chest pain (lasting more than 3 months after surgery, with daily use of pain killer) was reported in 24% of patients. Conclusion: CW resections with titanium reconstruction are associated with long-term survivors. Titanium devices were safe, reliable, and achieved satisfactory oncological results with low morbidity and implant-related complication rates.
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Efficient pain management is essential for postoperative rehabilitation in patients undergoing a tumor resection with an immediate reconstructive surgery. Ultrasound-guided quadratus lumborum block has been described for abdominal or hip surgery, but not for concomitant surgery in the abdomen and the thigh. The paraspinous transmuscular approach has easy landmarks to perform this block. We present a case of a patient undergoing a resection of a sarcoma in the lower limb with an immediate reconstruction with a pedicled vertical designed deep inferior epigastric perforator flap, in whom a successful paraspinous transmuscular quadratus lumborum block for postoperative analgesia was performed.
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Bloqueio Nervoso , Sarcoma , Analgésicos , Humanos , Dor Pós-Operatória/tratamento farmacológico , Sarcoma/cirurgia , Coxa da Perna/cirurgiaRESUMO
We reviewed the indications, peroperative feasibility, and postoperative clinical outcomes of our first 50 consecutive patients who underwent free flap reconstruction after TORS for complex pharyngeal defects at our institution. We analyzed indications according to previous radiotherapy, the size of the resection, and the transoral exposure of critical structures. We reviewed surgical data, postoperative complications, and functional outcomes comprising tracheostomy and alimentation management. Indications were upfront surgery (34%), a second primary surgery after radiotherapy (28%), or salvage surgery after chemoradiotherapy failure (38%). Localizations were the tongue base (44%), tonsillar fossa (28%), pharyngeal wall (22%), and soft palate (6%). T-classifications were T1 (6%), T2 (52%), T3 (20%), and T4 (22%). The mean length of the surgery was 574 min. Two patients were intraoperatively converted to a conventional approach at the beginning of the learning curve. In conclusion, TORS and free flap reconstruction in complex situations were associated with low rates of postoperative complications and satisfactory functional outcomes. They were, however, associated with a renewed learning curve.
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Oncological surgery of the parotid region sometimes requires the sacrifice of the facial nerve (parotid cancers, extensive skin cancers of the face, soft tissue sarcomas). The sacrificed portion of nerve can be reconstructed by a vascularized nerve graft, especially if the patient must undergo radiotherapy after surgery. In those cases, the facial nerve sacrifice is associated to an important loss of substance from the parotid region (skin, masseter, parotid, and sometimes jaw). Chimeric flap permit the reconstruction at the same time of the external skin, soft tissues for the volume (fat or muscle), nerve, and bone (ramus and angular part of the mandible). An other option was to raise two flaps but it increased the risk of failure (time of surgery, number of anastomosis, etc.). Reconstruction with a chimeric flap appears to be an ideal choice. Based on these observations, we offer our patients at the Gustave Roussy Institute (Villejuif, France) a thoracodorsal artery perforator (TDAP) free flap including the motor nerve of the latissimus dorsi and vascularized by the thoraco-dorsal pedicle, thus allowing reconstruction in a single surgery. The surgical technique is explained with a step-by-step video. Functional outcomes are also shown in the video. The TDAP or chimeric scapulo-dorsal flap with vascularized nerve has many advantages in the facial reanimation of patients suffering from parotid region cancers. This video article explains surgical steps for other teams.
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Retalhos de Tecido Biológico , Retalho Perfurante , Procedimentos de Cirurgia Plástica , Artérias , Nervo Facial/cirurgia , França , HumanosRESUMO
Robotic nipple-sparing mastectomy could be a significant advancement in the treatment and prophylaxis of selected breast cancers. Motion-scaling, high-resolution, three-dimensional optics; tremor elimination; and instruments with enhanced precision with 7 degrees of freedom have allowed surgeons to overcome the limitations experienced with the endoscopic approach in breast surgery. Advantages of this procedure, in comparison with the open technique, are a shorter and more acceptable scar located in the lateral thoracic region, and greater respect for the vascularization of the mastectomy skin flap, because there is no incision on the breast and no retractors are used. The authors recently received approval from both the French health authorities and the ethics committee to carry out a clinical trial in their institution to assess feasibility, reproducibility, and safety of robotic nipple-sparing mastectomy with immediate prosthetic breast reconstruction. The aims of this article are to describe the surgical technique they have developed, and to share, through a video, the clinical experience gained from over 60 procedures performed so far.
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Implante Mamário/métodos , Mastectomia Subcutânea/métodos , Procedimentos Cirúrgicos Robóticos/métodos , Feminino , Humanos , Avaliação de Resultados em Cuidados de SaúdeRESUMO
Breast cancer surgical treatment nowadays includes oncoplastic surgery. It is a reliable oncologic surgical treatment, which also prevents functional and aesthetic sequelae, thus improving the patient's quality of life and satisfaction. Numerous techniques have been described, with different levels of complexity and technicality. Their indications differ depending on the global breast volume and the degree of ptosis, on the tumor volume compared with the breast volume, and on the tumor location. This article describes the authors' many years of experience of breast cancer treatment using oncoplastic surgery. They also established a decision-making guide, whose implementation enables treatment of every patient.
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Neoplasias da Mama/cirurgia , Mamoplastia , Mastectomia Segmentar , Neoplasias da Mama/patologia , Estética , Feminino , Humanos , Seleção de Pacientes , Qualidade de VidaRESUMO
BACKGROUND: Patients undergoing free flap reconstruction after head and neck cancer may develop free flap complications. In the perioperative period, haemoglobin content and oxygen tissue saturation (StO2) measured directly on the free flap reflect peripheral tissue oxygenation. However, in this type of surgery, StO2 cannot always be applied directly or proximate to the free flap. The aim of this study was to assess the possible value of StO2 measured at the thenar eminence and other 24hour perioperative factors on free flap complications. METHODS: Inclusion criteria corresponded to patients with head and neck cancer with free flap surgery in whom direct StO2 could not be monitored on the flap nor in its peripheral area. Patient characteristics and intraoperative data, such as haemoglobin and fluid management, were prospectively collected. StO2 was measured remotely on the thenar eminence. Data were collected for 24hours and free flap complications were recorded for up to 15days after surgery. Patients were thereafter classified into two groups: with or without free flap complications and the data were compared in consequence. RESULTS: Forty consecutive patients were prospectively included. Ten patients had postoperative free flap complications and were compared to the 30 other patients without complications. The haemoglobin level at the reperfusion of the flap: (AUC 0.80 [0.65-0.91], threshold 9.9g/dL, P<0.001) and body mass index [BMI] (AUC 0.80 [0.64-0.72], threshold 24.5kg/m2, P<0.01) were significantly related to complications. CONCLUSION: In head and neck complex oncologic reconstructive surgery, haemoglobin and BMI were the most sensitive tools for predicting postoperative free flap complications, while thenar eminence StO2 was not.