The impact of COVID-19 pandemic on breast surgery in Italy: a multi-centric retrospective observational study.

COVID-19 pandemic had an impact on surgical activities. The aim of this multi-centric, retrospective study was to evaluate the impact of the COVID-19 pandemic on breast surgery. The patients who operated during the pre-pandemic year 2019 were compared to those operated in 2020. Fourteen Breast Care Units provided data on breast surgical procedures performed in 2020 and 2019: total number of breast-conserving surgery (BCS), number of 1st level oncoplastic breast surgery (OBS), number of 2nd level OBS; total number of mastectomies, mastectomies without reconstruction, mastectomies with a tissue expander, mastectomies with direct to implant (DTI) reconstruction, mastectomies with immediate flap reconstruction; total number of delayed reconstructions, number of expanders to implant reconstructions, number of delayed flap reconstructions. Overall 20.684 patients were included: 10.850 (52.5%) operated during 2019, and 9.834 (47.5%) during 2020. The overall number of breast oncologic surgical procedures in all centers in 2020 was 8.509, compared to 9.383 in 2019 (- 9%). BCS decreased by 744 cases (- 13%), the overall number of mastectomies decreased by 130 cases (- 3.5%); mastectomy-BCS ratio was 39-61% in 2019, and 42-58% in 2020. Regarding immediate reconstructive procedures mastectomies with DTI reconstruction increased by 166 cases (+ 15%) and mastectomies with immediate expander reconstruction decreased by 297 cases (- 20%). Breast-delayed reconstructive procedures in all centers in 2020 were 142 less than in 2019 (- 10%). The outburst of the COVID-19 pandemic in 2020 determined an implemented number of mastectomies compared to BCS, an implemented number of immediate breast reconstructions, mainly DTI, and a reduction of expander reconstruction.

Microsurgery "without borders": new limits for reconstruction of post-burn sequelae in the humanitarian setting.

Post-burn contractures account for up to 50% of the workload of a plastic surgery team volunteering in developing nations. Best possible outcome most likely requires extensive surgery. However, extensive approaches such as microsurgery are generally discouraged in these settings. We report two successful cases of severe hand contractures reconstructed with free flaps on a surgical mission in Kenya. Microsurgery can be safely performed in the humanitarian setting by an integration of: personal skills; technical means; education of local personnel; follow-up services; and an effective network for communication.

Les rétractions après brûlures constituent 50% de l'occupation d'une équipe humanitaire de chirurgie plastique dans les pays en voie de développement. Les meilleurs résultats possibles nécessitent une chirurgie lourde. Cependant certaines de ces approches comme la microchirurgie ne sont généralement pas encouragées dans ce cadre. Nous rapportons deux cas successifs de rétractions majeures de la main, réparées par lambeaux libres dans une mission chirurgicale au Kenya. La microchirurgie peut donc être réalisée en toute sécurité dans le cadre humanitaire, à condition de bénéficier d'une expérience personnelle, de moyens techniques appropriés, de l'éducation du personnel local, des services de suite et enfin d'un réseau effectif de communication.

Shoulder function after breast reconstruction with the latissimus dorsi flap: A prospective cohort study - Combining DASH score and objective evaluation.

OBJECTIVES: The latissimus dorsi (LD) flap is well-known in breast reconstruction especially in previously-irradiated patients, in order to have a low capsular contraction rate whenever an implant is associated. The aim of this study is to closely evaluate the effect of LD flap harvesting on shoulder function as well as specific movements related to the LD, both objectively and subjectively. MATERIALS AND METHODS: We retrospectively collected data on 86 patients who underwent pedicled LD muscle flap for breast reconstruction at the European Institute of Oncology between September 1995 until March 2011. RESULTS: The majority of patients showed a joint recovery superior to 80% in all joint movements examined. Disabilities of the Arm, Shoulder and Hand questionnaire revealed minimal disability similar to normal range and furthermore it appears to decrease in all sports and in particular in those who practice with LD involvement. CONCLUSION: Focusing this data, a growing, "disability-free" percentage changes depending on whether or not the patients have practiced sport could be appreciate.

Barcelona consensus on supermicrosurgery.

The popularity of supermicrosurgery has increased dramatically over the past few years, but the lack of agreement regarding the name of the technique and its applications has caused misunderstandings among microsurgeons when trying to communicate and compare surgical procedures. We report the consensus reached on the name used to refer to supermicrosurgery techniques following the First European Conference on Supramicrosurgery held in Barcelona (Spain) on March 4-5, 2010. Present applications, advantages, and disadvantages of supermicrosurgery are discussed. It was agreed that supermicrosurgery was the most accurate name to reflect the essence of this extremely delicate technique. According to Koshima, supermicrosurgery is a technique of microneurovascular anastomosis for vessels of 0.3 to 0.8 mm and single nerve fascicles. The range of applications for this technique has increased rapidly and now includes lymphedema treatment, nerve reconstruction, replantation and reconstruction of amputated fingertips, microsurgical flap salvage, and new possibilities for free tissue transfer. Supermicrosurgery is a remarkably useful reconstructive tool that involves a great deal of skill and has a steep learning curve for the microsurgeon to master. Although it is currently performed by only a minority of microsurgeons, we consider it will be incorporated into conventional microsurgery in the near future.

Evaluation of fat grafting safety in patients with intraepithelial neoplasia: a matched-cohort study.

BACKGROUND: Fat grafting is widely carried out in breast cancer patients to improve quality in breast reconstruction. Recently, in vitro and animal studies have questioned the role of adipose tissues in cancer development. DESIGNS: Matched-cohort study. We analysed: (i) 59 intraepithelial neoplasia patients who had undergone lipofilling, with no recurrence between primary surgery and lipofilling. (ii) A control group of 118 matched patients (two controls per lipofilling patient) with the corresponding recurrence-free intervals. Both groups were also matched for main cancer criteria. A local event (LE) was the primary end point, with follow-up starting from the baseline. RESULTS: Median follow-up was 63 and 66 months from surgery, and 38 and 42 from baseline, for the lipofilling and control groups, respectively; the 5-year cumulative incidence of LE was 18% and 3% (P = 0.02). Ki-67 was the significant factor in univariate survival analysis. A subgroup analysis showed that lipofilling increased the risk of LE in women <50 years, with high grade neoplasia, Ki-67 ≥ 14 or who had undergone quadrantectomy. CONCLUSION: Higher risk of LE was observed in intraepithelial neoplasia patients following lipofilling. Although further studies are required to validate our conclusions, patients belonging to this subgroup should be informed of these results and the potential risks.

Locoregional recurrence risk after lipofilling in breast cancer patients.

BACKGROUND: Lipofilling has been indicated for postmastectomy and postlumpectomy breast reconstruction. The clinical literatures underline its technical efficacy but experimental studies raise important questions about the potential detrimental effect of adipocytes on the stimulation of cancer growth and reappearance. DESIGN: We collected 321 consecutive patients operated for a primary breast cancer between 1997 and 2008 who subsequently underwent lipofilling for reconstructive purpose. For each patient, we selected two matched patients with similar characteristics who did not undergo a lipofilling. RESULTS: Eighty-nine percent of the tumors were invasive. Median follow-up was 56 months from the primary surgery and 26 months from the lipofilling. Eight and 19 patients had a local event in the lipofilling and control group, respectively, leading to comparable cumulative incidence curves [P = 0.792; Hazard Ratio(Lipo vs No lipo) = 1.11 (95% confidence interval 0.47-2.64)]. These results were confirmed when patients undergoing quadrantectomy and mastectomy were analyzed separately and when the analysis was limited to invasive tumors. Based on 37 cases, the lipofilling group resulted at higher risk of local events when the analysis was limited to intraepithelial neoplasia. CONCLUSIONS: Lipofilling seems to be a safe procedure in breast cancer patients. Longer follow-up and further experiences from oncological series are urgently required to confirm these findings.

Nipple sparing mastectomy with nipple areola intraoperative radiotherapy: one thousand and one cases of a five years experience at the European institute of oncology of Milan (EIO).

In order to reduce mutilation, nipple-areola complex (NAC) conservation can be proposed for the treatment of breast cancer when mastectomy is indicated. To reduce the risk of retro areolar recurrence, a novel radiosurgical treatment combining subcutaneous mastectomy with intraoperative radiotherapy (ELIOT) is proposed. One thousand and one nipple sparing mastectomies (NSM) were performed from March 2002 to November 2007 at the European institute of oncology (EIO), for invasive carcinoma in 82% of the patients and in situ carcinoma in 18%. Clinical complications, aesthetic results, oncological and psychological results were recorded. A comparison was performed between the 800 patients who received ELIOT and the 201 who underwent delayed one-shot radiotherapy on the days following the operation. The median follow up time was 20 months (range 1-69) for a follow up performed in 83% of the patients. The NAC necrosed totally in 35 cases (3.5%) and partially in 55 (5.5%) and was removed in 50 (5%). Twenty infections (2%) were observed and 43 (4.3%) prostheses removed. The median rate of the patients for global cosmetic result on a scale ranging from 0 (worst) to 10 (excellent) was 8. Evaluation by the surgeon in charge of the follow-up gave a similar result. Only 15% of the patients reported a partial sensitivity of the NAC. Of the fourteen (1.4%) local recurrences, ten occurred close to the tumour site, all far from the NAC corresponding to the field of radiation. No recurrences were observed in the NAC. In a group of patients characterized by a very close free margin under the areola, no local recurrence was observed. Overall, 36 cases of metastases and 4 deaths were observed. No significant outcome difference was observed between the 800 patients receiving intraoperative radiotherapy (ELIOT) and the 201 patients receiving delayed irradiation.

Nipple-sparing mastectomy: risk of nipple-areolar recurrences in a series of 579 cases.

BACKGROUND: When the conservative treatment is not recommended, Nipple Sparing Mastectomy (NSM) is proposed more and more frequently for the surgical treatment of breast cancer. The risk of local recurrence behind the nipple areolar complex (NAC) is the main limiting factor of the NSM procedure. To minimize such risk, we proposed in 2002 a intraoperative radiotherapy of the preserved NAC. PATIENTS AND METHODS: From March 2002 to November 2006, 579 cases (in 570 patients) of NSM were performed for carcinoma. The median follow up time was 19 months (Range: 1-60). The subcutaneous mastectomy was performed through an incision removing a portion of the skin overlying the tumour. An extemporaneous histological examination was performed on the retroareolar glandular tissue. If the histology was positive the patient was not considered eligible. Then an intraoperative radiotherapy with electrons (ELIOT) of 16 Gy in one shot was delivered on the NAC area. An immediate breast reconstruction was done using implants in most cases and in several cases a musculocutaneous flaps, usually in large breast. The number of local recurrences was recorded and the correlation between their occurrence and the clinical and histological criteria were analysed using the Gray test statistical method in a competing framework. RESULTS: In 516 cases the negative retroareolar frozen section biopsy was confirmed by the final histology, while in 63 cases, the final histology showed foci of carcinoma. Seven out of these 63 cases underwent a secondary NAC removal. In the 56 cases which preserved areolas we did not observe any local recurrence after 19 months follow up. The probability of retro areola positive histology increases with the tumour size. and was not related to the nodal status. The rate of local relapses was 0.9% per year. We didn't find any significant difference in the local relapse rate according to different patient's and tumour's features. Most relapses were located close to the tumour bed but never in the NAC area. CONCLUSION: Our study confirms that the local recurrence rate in the NSM completed with local radiotherapy on the NAC is not higher than the usual rate observed in the literature and the preservation of the NAC does not increase the risk. The absence of local recurrence in the region where a portion of glandular tissue has been purposely preserved is a good argument in favour of ELIOT.

Oncological results of immediate breast reconstruction: long term follow-up of a large series at a single institution.

BACKGROUND: Reconstruction of the breast after mastectomy is an integral part of the complete management of breast cancer. However, a delay in the reconstruction is usually proposed after the mastectomy in case of invasive cancer, while there is a general agreement for immediate breast reconstruction in case of in situ tumors. PATIENTS AND METHODS: Among a total of 677 patients having undergone a mastectomy between 1997 and 2001, 518 (76.5%) underwent an immediate breast reconstruction (IBR). All the patients had a Patey mastectomy for invasive cancer (T1-T3). An adjuvant medical treatment was given according to the biological characteristics of the tumor and lymph node status. No patient received any kind of radiotherapy. The median follow up was 70 months (range 13-114). RESULTS: The local recurrence rate was 5.2% for the group of IBR and 9.4% for the mastectomy group without IBR (NoIBR). The regional metastases rate was 1.4 vs. 1.3%. The rate of distant metastases was 13.9 vs. 16.4%. Contra-lateral breast tumor was observed in 1.5 vs. 1.3%. Death rate was 10.4 vs. 16.4%. No statistical difference was observed between the two groups in terme of overall survival (OS) and disease free survival (DFS) (HR(IBR vs. NoIBR): 1.03 and 0.99 for OS and DFS, respectively). CONCLUSION: At our institution we have compared a large series that have undergone IBR (518) with a control group (159) and followed over a prolonged period of time (70 months). This study provides the best available results to suggest that IBR is a safe and reliable treatment option for the managing invasive breast cancer.

Long-term oncological results of breast conservative treatment with oncoplastic surgery.

Oncoplastic surgery combining breast conservative treatment (BCT) and plastic surgery techniques may allow more extensive breast resections and improve aesthetic outcomes, but no long-term oncological results have been published. Long-term oncologic results of 148 consecutive BCT with concomitant bilateral plastic surgery have been analysed and were compared to historical data of BCT trials. Median follow-up was 74 months. Complete excision was obtained in 135 patients (91%); focally involved margins in 8 (5%); and close (<2 mm) margins in 5 (3%). Five patients developed ipsilateral recurrence (3%), 19 (13%) developed distant metastasis and 11 patients died (7.53%). Patients with tumours larger than 2 cm were at greater risk of local recurrences and distant metastasis. Long-term oncologic results of BCT with oncoplastic surgery are comparable with the results of BCT randomized trials.

Evaluation of skin perfusion after nipple-sparing mastectomy by indocyanine green dye. Preliminary results.

The aim of the study was to investigate the blood supply of the normal nipple areola complex (NAC) and the spared areola complex after a nipple-sparing mastectomy using the analysis of the fluorescence from the indocianine green dye (ICG) injection. Between December 2002 and July 2003 we performed the ICG analysis in 10 cases of healthy breasts and in 9 patients after a nipple-sparing mastectomy and one patient after subcutaneous mastectomy. In all cases, the resulting fluorescence was measured in three different zones: nipple, areola, surrounding mammary skin. Three parameters of the fluorescence curve (slope, maximum intensity, time to achieve a maximum level) were recorded. On the healthy breast, the nipple showed a very high perfusion as compared to the other zones. On the contrary, after the mastectomy the fluorescent pattern was completely altered, being the perfusion of the nipple very low. In conclusion, these preliminary results confirm the applicability and the importance of the ICG technique for evaluating the perfusion of the healthy and spared areola after surgery. Because of the small number of patients further studies are needed.

When mastectomy becomes inevitable: the nipple-sparing approach.

The preservation of the nipple areola complex (NAC) could improve the quality of life in cases of mastectomy. A novel radiosurgical treatment combining subcutaneous mastectomy with intraoperative radiotherapy is proposed. Three hundred nipple-sparing mastectomies (NSM) were performed. Invasive (58%) and in situ (42%) carcinomas were included. Clinical complications, aesthetic results, oncological and psychological results were recorded. The NAC necrosed totally in 10 cases and partially in 29 and it was removed in 12. Nine infections (3%) were observed and 10 prostheses removed. Good results were rated by 82.3% of the patients and by 84.8% of the surgeons. In 7.5% a radiodystrophy was observed. The sensitivity of the NAC recovered partially in 48%. Two local recurrences occurred outside the radiated field. Overall, we observed three metastases and no deaths. Sixty-eight of the patients were satisfied with their reconstructed breast and 85.5% were satisfied having preserved the NAC.

Immediate breast reconstruction and high-dose chemotherapy.

BACKGROUND: Immediate breast reconstruction (IBR) is considered as a safe procedure nowadays, and it can be proposed in the majority of patients requiring a mastectomy. In fact, recent studies have demonstrated that immediate breast reconstruction is not detrimental also to patients with locally advanced breast cancers. However, IBR should be reevaluated in case of locally advanced breast cancer requiring high-dose chemotherapy (HDCT). The aim of this study is to evaluate both the risk of chemotherapy delay due to surgical complications and the risk of late surgical complications related to the association with HDCT. We considered 3 series of 23, 67, and 15 patients requiring a mastectomy at the European Institute of Oncology in Milan. After mastectomy, these groups respectively received an IBR and HDCT, an IBR and conventional chemotherapy, and only HDCT with no IBR. METHODS: Files of 105 patients who were admitted to our department from October 1999 to January 2002 were reviewed. Twenty-three patients underwent a mastectomy, followed by IBR and HDCT; 67 underwent a mastectomy plus IBR plus conventional CT; and, finally, 15 underwent a mastectomy alone followed by HDCT. The reconstructive techniques performed were 72 permanent prosthesis and 18 temporary expanders. We excluded all patients with IBR by flap (latissimus dorsi or pedicled rectus abdominis) to improve the homogeneity of the sample. RESULTS: All patients who underwent IBR started high-dose chemotherapy without any delay; the time elapsed between surgery and HDCT is not significantly different for patients with and without IBR (54 versus 60 days, P = 0.13). The early complication rate (before CT) was 2.9% (2 patients with infection). The late complication rate (after CT) was higher for the group that underwent IBR followed by HDCT (39% versus 20%). CONCLUSION: We did not observe any delay for the administration of high-dose chemotherapy after mastectomy with IBR surgery. The complication rate before HDCT is similar to the complication rates published in the literature. On the contrary, we observed a higher rate of infections (13% versus 0%, P = 0,014) after HDCT than after conventional CT, which can be related to the association with high-dose chemotherapy, inducing a decrease of the immune defenses. These results seems to demonstrate that the association of IBR with HDCT is not detrimental to patients from the oncological point of view, but the impact of HDCT on the reconstruction is more negative. Further studies are needed to verify if this risk exists, although lower, in the association with conventional CT. However, a careful evaluation of the risk of infections should be considered preoperatively, and perioperative contaminations should be carefully prevented.

Breast reconstructive techniques in cancer patients: which ones, when to apply, which immediate and long term risks?

Breast reconstruction is considered as part of the breast cancer treatment when a mastectomy is required. The techniques available today, allow reconstruction of the breast even in almost all the cases even in poor local conditions. In 60-70% of the cases, the reconstruction can be performed with an implant inserted behind the pectoralis muscle. Special implants called expanders, are inflatable progressively in the postoperative course thanks to a reservoir located subcutaneously. They provide a progressive distention of the teguments and a more natural shape after substitution of the expander with a definitive implant. The symmetry is usually obtained thanks to a contralateral plastic surgery, which allows at the same time histological check up of the glandular tissue of the opposite breast. The nipple areolar complex is usually reconstructed in a second stage under local anesthesia, using local flaps for the nipple and a tattoo for the colour of the areola. In 30% of the cases, especially after radiotherapy when a salvage mastectomy is required, a flap reconstruction is preferred. The autologous tissue reconstruction with the rectus myocutaneous flap gives excellent cosmetic results and the most natural shape for the breast. But it is a more demanding technique requiring a good experience. In some occasions, the reconstruction with the latissimus flap can also be autologous but usually requires the addition of prosthesis. In most cases, the reconstruction can be performed immediately. The delayed reconstruction is usually preferred when the adjuvant chemotherapy should be delivered as soon as possible after the mastectomy. Complications of the reconstruction such as local necrosis or infections, leading to implant removal or revision of the flap could be detrimental to the patient in delaying the start of the chemotherapy. It is not recommended to reconstruct the breast immediately in case of locally advanced breast cancer. Partial breast reconstruction using plastic surgery procedures can also be performed in case of quadrantectomy in order to obtain a better cosmetic result. Local glandular flaps, as well as specific incisions according to the location of the tumor in the breast allow the reshaping of the breast even in case of large resection and, therefore, provide an opportunity to increase the number of conservative treatment indications, especially in case of in-situ carcinomas.

Integration of plastic surgery in the course of breast-conserving surgery for cancer to improve cosmetic results and radicality of tumor excision.

Integration of plastic surgery is currently widely practiced in cases of mastectomy. Immediate breast reconstruction with an implant or autologous tissue procedures is frequently proposed to the patient before the mastectomy. However, breast conserving surgery (BCS) is recognized as the treatment of choice in most cancers: breast conservation is proposed in more than 70% of the patients with primary cancer treated at the European Institute of Oncology in Milan. This high percentage of preservation has been made possible by the integration of plastic surgery at the time of primary surgery. The size of the tumorectomy remains a matter of discussion. Based on the Milan II trial and Holland's pathological studies, Veronesi recommended so-called "local radical surgery." For a tumor 1 cm in size, a free margin of 2 cm produces a final specimen at least 5-6 cm in diameter. In small or medium-sized breasts, such a resection results in a wide glandular defect and poor esthetic results if direct closure is carried out. Plastic surgery derived from reduction mammaplasty procedures allows much better final cosmetic results, which is the goal of conservative treatment. In 25% of our patients treated with BCS, the plastic surgeon is called upon by the general surgeon to close the glandular defect. However, such glandular remodeling changes the size and position of the breast. Therefore, in 15% of these cases a symmetry procedure is performed on the opposite breast. The reduction procedure in the opposite breast should be taken as a good opportunity to check the glandular tissue. Special attention should therefore be given to the contralateral mammogram in order to focus the glandular resection on the most dubious areas. Occult carcinomas, half of them infiltrating, were found in 4% of a series of 350 symmetry procedures performed during breast reconstruction at the Gustave Roussy Cancer Institute. In conclusion, close collaboration between oncologists and plastic surgeons is required not only to obtain the best cosmetic results but also to allow improved radicality of the tumor resection and a histological check-up of the contralateral breast.

[Mammoplasty for symmetry of the contralateral breast and its oncologic value]. / Les plasties mammaires dans la symétrisation du sein controlatéral et leur intérêt carcinologique.

Controlateral occult carcinomas are observed in 3 to 5% of the reduction mammaplasty of the controlateral breast at the time of the breast reconstruction. The symmetry procedure allows a good check up of the glandular tissue of the controlateral breast, especially when there is no evidence of tumor. The different techniques of breast reduction provide specific possibilities for such exploration and should be chosen according to the area which should be explored. The superior pedicle technique gives us the best exposure and an easier modelling. It gives a good aesthetic results in 80% of cases. The central pedicle and dermoglandular pedicle technique give a good exposure and permits us to fill the defect with glandular flap. The drawback of the inferior pedicle technique is the lack of control of the central and inferior quadrant.

[Role of plastic surgery in the conservative treatment of breast cancer]. / La place de la chirurgie plastique dans le traitement conservateur du cancer du sein.

Conservative surgery (CS) is widely accepted today as the treatment of choice for 60 to 80% of the primary breast cancer. Esthetic results of CS are not good in all the cases and improvement can be obtained thanks to the remodelling of the breast after tumorectomy. The scar should be selected according to the location of the tumor; the glandular tissue should be reshaped using local glandular flaps or following the principles of the reduction mammaplasties. Tumorectomy located in the upper part of the gland can be reshaped with an inferior pedicle type of mammoplasty. Defect located in the inferior part of the gland can be reconstructed with a superior pedicle mammoplasty. These sophisticated tumorectomies are providing good esthetic results on the reconstructed breast but require commonly a symmetry procedure on the contralateral breast. Such contralateral reduction allows a better exploration of the opposite breast and histological examination of the reduction specimen. In a series of 76 CS performed at the European Institute of Oncology (IEO), which were associated with some kind of plastic procedure to lower the risk of bad cosmetic results (representing 25% of the CS associated with plastic surgery), we confirmed the value of the mixed oncologic and plastic approach. The esthetic results observed in this series are better than those observed in another series previously published at the Gustave-Roussy Institute (IGR)--good results: 72% (IEO) vs 50% (IGR), and bad results: 6% (IEO) vs 20% (IGR). Statistically such comparison can be criticised, specially because of the short follow-up of the Milan series. However, the difference is rather important if we consider that the series of Milan was a selection of cases with poor esthetic expectation (25% of all the CS performed during the same period), while the series of Paris did not select the patients in what concerns the risk of poor esthetic result.

[Cutaneous suspension: immediate breast reconstruction with abdominal cutaneous advancement using a non-resorptive mesh. Preliminary results and report of 28 cases]. / La suspension cutanée: reconstruction mammaire immédiate avec avancement cutané abdominal à l'aide d'une plaque non résorbable. Résultats préliminaires à propos de vingt-neuf cas.

The immediate breast reconstruction with a definitive prosthesis (IBRDP) is the most useful technique in our experience. We proposed a technique to allow the use of IBRDP also in cases of mastectomy with large skin excision and also to permit a better definition of the inframammary fold. The prosthesis pocket is prepared as usually with the pectoralis major and serratus anterior muscles and then, a skin flap is undermined about 6-8 cm below the inframammary fold to prepare an upper abdominal skin flap. The innovation point is the use of a triangular non absorbable mersilene mesh to pull up and maintain the flap. The mesh is initially sutured at the future inframammary fold projection 4 to 6 cm lower than the previous inframammary fold and sutured under tension to the third and fourth costal cartilages. The prosthesis is located in front of the mesh and behind the muscles. Twenty nine patients had a mastectomy with IBRDP with the "Cskin suspension" technique at European Institute if Oncology (IEO) from june 1995 to september 1996. Only one case (3.4%) had a prosthesis loss 3 months after the surgery, probably by a prosthetic material rejection. This technique permits an IBRDF for the patients with a good abdominal skin laxity and also avoids the use of a more complicate or a more expensive technique (myocutaneous flaps or skin expanders). The small post-operative complications rate must be confirmed by a larger follow-up to evaluate the capsular contracture rates and the final cosmetic results.