[Breast reconstruction by prosthesis]. / La reconstruction mammaire par prothèse.

Breast reconstruction by prosthesis remains the most used in the world and even tends to increase again at the expense of musculo-cutaneous flaps since the systematic use, in recent years, of adipocytes grafts (lipofilling) before and/or after in place of the implant. This simpler technique is often preferred by patients who want to avoid scars and pain away from the chest area. The use of different implant forms, fat injection, abdominal advancement flaps, biological or synthetic matrices can significantly improve the results of these reconstructions in secondary or immediate. All these techniques are detailed in the following article to show the different devices that allow to achieve this intervention with maximum security.

[Identification of perforating vessels by augmented reality: Application for the deep inferior epigastric perforator flap]. / Repérage des vaisseaux perforants par réalité augmentée : application au lambeau perforant d'artère épigastrique inférieure profonde.

The augmented reality on smart glasses allows the surgeon to visualize three-dimensional virtual objects during surgery, superimposed in real time to the anatomy of the patient. This makes it possible to preserve the vision of the surgical field and to dispose of added computerized information without the need to use a physical surgical guide or a deported screen. TECHNIQUE: The three-dimensional objects that we used and visualized in augmented reality came from the reconstructions made from the CT-scans of the patients. These objects have been transferred through a dedicated application on stereoscopic smart glasses. The positioning and the stabilization of the virtual layers on the anatomy of the patients were obtained thanks to the recognition, by the glasses, of a tracker placed on the skin. We used this technology, in addition to the usual locating methods for preoperative planning and the selection of perforating vessels for 12 patients operated on a breast reconstruction, by perforating flap of deep lower epigastric artery. The "hands-free" smart glasses with two stereoscopic screens make it possible to provide the reconstructive surgeon with binocular visualization in the operative field of the vessels identified with the CT-scan.

Prediction of axillary lymph node status in male breast carcinoma.

BACKGROUND: To evaluate whether predictive factors of axillary lymph node metastasis in female breast cancer (BC) are similar in male BC. PATIENTS AND METHODS: From January 1994 to May 2011, we recorded 80 non-metastatic male BC treated at Institut Curie (IC). We analysed the calibration and discrimination performance of two nomograms [IC, Memorian Sloan-Kettering Cancer Center (MSKCC)] originally designed to predict axillary lymph node metastases in female BC. RESULTS: About 55% and 24% of the tumours were pT1 and pT4, respectively. Nearly 46% demonstrated axillary lymph node metastasis. About 99% were oestrogen receptor positive and 94% HER2 negative. Lymph node status was the only significant prognostic factor of overall survival (P = 0.012). The area under curve (AUC) of IC and MSKCC nomograms were 0.66 (95% CI 0.54-0.79) and 0.64 (95% CI 0.52-0.76), respectively. The calibration of these two models was inadequate. CONCLUSIONS: Multi-variate models designed to predict axillary lymph node metastases for female BC were not effective in our male BC series. Our results may be explained by (i) small sample size (ii) different biological determinants influencing axillary metastasis in male BC compared with female BC.

Lateral mammaplasty reconstruction after surgery for breast cancer.

BACKGROUND: Up to 60 per cent of cancers develop laterally in the breast and breast-conserving surgery frequently produces superolateral nipple-areolar complex (NAC) distortion aggravated by postoperative irradiation. Correction is technically demanding and the outcomes are variable. Lateral mammaplasty may allow wider excision margins and prevent such deformities. METHODS: This was a review of 86 consecutive patients who had lateral mammaplasty: combined wide tumour excision with NAC repositioning on a reliable dermoglandular pedicle. Simultaneous axillary surgery was performed via a separate or combined incision. Aesthetic outcomes were assessed. RESULTS: The median age of the women was 54 (range 29-75) years; 55 (64 per cent) had palpable tumours and 73 (85 per cent) underwent simultaneous axillary surgery. Median radiological and histological tumour sizes were 29.8 and 33.6 mm, respectively, and median weight of excised tumour was 150 g. Two patients required haematoma evacuation. Eleven women required revisional surgery for involved or close margins. Aesthetic outcomes were excellent or good in 93 per cent. CONCLUSION: Lateral mammaplasty produced clear margins in 87 per cent of women. It is an option when a deformity is anticipated after breast-conserving surgery, and is particularly valuable when neoadjuvant chemotherapy has downgraded a large tumour.

[Secondary breast reconstruction using exclusive lipofilling]. / Reconstruction mammaire secondaire par lipomodelage exclusif.

Lipofilling is usually performed in breast surgery for treatment of aesthetics sequelae after breast conserving surgery or correction after breast reconstruction by prothesis or musculocutaneous flaps. We present a case of a patient where exclusive lipofilling breast reconstruction has been successfully performed. Aesthetic result is assessed by the patient and the surgeon as very satisfactory after one year of follow-up. This technology not much used in this present indication have important advantages in terms of tolerance or morbidness but the long-term results depend on not controlled factors such as volumetric cast iron or fatty resorption. Further studies are necessary to define the patients will be able to benefit from this technology and to assess the modalities of follow-up but also to measure evenly practicability, stability of reconstruction and its evolution in time. However, aesthetic result and contentment of the patient allow us to envisage the broadcasting of this technology of mammary reconstruction for selected patients.

Intraoperative augmented reality with heads-up displays in maxillofacial surgery: a systematic review of the literature and a classification of relevant technologies.

Although the term augmented reality appears increasingly in published studies, the real-time, image-guided (so-called 'hands-free' and 'heads-up') surgery techniques are often confused with other virtual imaging procedures. A systematic review of the literature was conducted to classify augmented reality applications in the fields of maxillofacial surgery. Publications containing the terms 'augmented reality', 'hybrid reality', and 'surgery' were sought through a search of three medical databases, covering the years 1995-2018. Thirteen publications containing enough usable data to perform a comparative analysis of methods used and results obtained were identified. Five out of 13 described a method based on a hands-free and heads-up augmented reality approach using smart glasses or a headset combined with tracking. Most of the publications reported a minimum error of less than 1mm between the virtual model and the patient. Augmented reality during surgery may be classified into four categories: heads-up guided surgery (type I) with tracking (Ia) or without tracking (Ib); guided surgery using a semi-transparent screen (type II); guided surgery based on the digital projection of images onto the patient (type III); and guided surgery based on the transfer of digital data to a monitor display (type IV).

[Breast cancer surgery: use of mammaplasty. Results. Series of 298 cases]. / Résultats carcinologiques et esthétiques du traitement du cancer du sein par plastie mammaire. 298 cas.

Breast cancer surgery has long consisted in the sole use of mastectomy. Then, it was proved that, in terms of global survival, conservative treatments associated with radiotherapies could give the same results. But breast deformations due to classic conservative treatments led some authors to use plastic surgery procedures: breast plastic surgery. Some breast plastic surgery procedures are well-known, others have been adapted to breast cancer treatment and more particularly in case of tumor of superior and internal quadrants. After the retrospective analysis of a series of 298 cases from the Institute Curie, the aim of this survey is to find whether there is a difference between: breast plastic surgery and usual treatments like mastectomy and classic conservative treatments. For most cases, the tumors were invasive ductal carcinoma and T2N0M0 carcinoma. This survey showed, among these cases, 94.56% of global survival, 86.81% of survival without metastasis and a five-year 93.47% without local recurrence, which is comparable to the results for mastectomies and classic conservative treatments. In selected cases, the use of mammaplasty could be interesting for breast cancer surgery treatment.

[Nipple and areola reconstruction by tattooing, "F" and "Z" flaps]. / La reconstruction de la plaque aréolo-mamelonnaire par tatouage, lambeaux << F >> et << Z >>

Nipple and areola reconstruction is very important in the evaluation of the quality of breast reconstruction. It can be done during the primary or secondary breast reconstruction or later. We have performed the techniques of nipple reconstruction routinely since 1992. Under local anesthesia during a second operative time or general anesthesia during breast reconstruction, the local "F" and "Z" skin flaps and tattooing grant a quality result in the wound and the long-term projection. They are easily reproduced, rapid and as there is no graft the choice of the incisions grants a good tolerance. Complications are rare and it is always possible to use other techniques in case of poor result. We also present the main techniques of nipple and areola reconstruction with their advantages and limits.

[Partial reconstruction after conservative treatment for breast cancer: classification of sequelae and treatment options]. / Séquelles esthétiques du traitement conservateur des cancers du sein: une classification pour les reconstructions après tumorectomie.

Most patients presenting with breast cancer are treated by breast conserving treatment (BCT). Some of these patients present with poor cosmetic results and ask for partial breast reconstruction. These reconstructions following BCT are presenting more frequently to plastic surgeons as a difficult management problem. We have defined and published a classification of the different cosmetic sequelae (CS) after BCT into three types. This classification helps to analyse these complex deformities aggravated by radiotherapy. Furthermore, our classification helps to choose between the different surgical techniques and propose the optimal option for their surgical correction. Our initial publications reported 35 and 85 patients: we have currently operated more than 150 cases of CS after BCT. Type-1 CS are defined by an asymmetry between the two breasts, with no distortion or deformity of the radiated breast. Type-2 CS are those with an obvious breast deformity, that can be corrected with a partial reconstruction of the breast. Type-3 CS are those with such a deformity that only a mastectomy with total reconstruction of the breast can be performed. Most of the patients present with type-2 CS, but are reluctant to undergo what they feel is a major reconstructive procedure: in a initial prospective series of 85 patients operated for CS after BCT, 48 (56.5%) had type-1 CS, 33 patients (38.8%) type-2 CS and four patients (4.7%) type-3 CS. Type-1 patients should be managed essentially by contralateral symmetrizing procedures. One should limit any surgery on the radiated breast, as a mammoplasty or an augmentation is at high risk of complications. Type-2 is the most difficult to manage and requires all the surgical armamentarium of breast reconstructive surgery. The insetting of a myocutaneous flap is often necessary and autologous fat grafting is a promising tool in selected cases. Type-3 CS requires mastectomy and immediate reconstruction with a myocutaneous flap. The major development though in the past 10 years has been the development of oncoplastic techniques at the time of the original tumour removal, in order to avoid most of type 2 and type 3 deformities. This paper reaffirms the validity of the Cosmetic Sequelae classification as a simple, practical guide for breast reconstructive surgeons. It discusses the various choices of reconstructive procedures available, the importance of "preventing" these CS and defining the role of the plastic surgeon in the management of these patients.

Conservative treatment of lower pole breast cancers by bilateral mammoplasty and radiotherapy.

AIMS: This series analyses the results of conservative surgery for large lower pole breast cancers by lumpectomy associated with a bilateral remodelling mammoplasty, in order to avoid residual deformities. METHODS: This retrospective study concerns 50 patients with a lower pole breast cancer treated between 1986 and 1996 by lumpectomy, mammoplasty and irradiation. The contralateral breast was immediately made symmetrical in all cases. The mean tumour size was 32.5 mm. RESULTS: The mean weight of the lumpectomy specimen was 270 g. Resection margins were tumour-free in 90% of cases. The main complication observed was delayed healing, thus postponing post-operative treatment in 6.5% of cases. The median follow-up was 48 months. The 5-year actuarial ipsilateral local recurrence rate was 7% and 5-year actuarial metastasis-free and overall survival rates were 81 and 97%, respectively. Cosmesis was satisfactory in 85% of patients. We observed better results when radiotherapy was performed after rather than prior to surgery (92 vs. 67%: NS). CONCLUSIONS: Performing a bilateral mammoplasty at the time of initial surgery for large breast cancers situated in the lower quadrants of the breast facilitates larger lumpectomies with good cosmetic results.

Prospective evaluation of late cosmetic results following breast reconstruction: I. Implant reconstruction.

The long-term cosmetic outcome of breast implant reconstruction is unknown. The morbidity and cosmetic outcome of 360 patients who underwent immediate postmastectomy breast reconstruction with various types of implants have been analyzed prospectively over a 9-year period. Of these patients, 334 who completed their reconstruction were suitable for evaluation of their cosmetic outcome. The early complication rate (< 2 months) was 9.2 percent, with an explantation rate of 1.7 percent. The late complication rate (> 2 months) was 23 percent, with a pathological capsular contracture rate of 11 percent at 2 years and 15 percent at 5 years and an implant removal rate of 7 percent. The revisional surgery rate was 30.2 percent. The cosmetic results were assessed prospectively using an objective five-point global scale. Every patient was scored at each visit once surgery was completed. The overall cosmetic outcome deteriorated in a linear fashion, from an initial acceptable result of 86 percent 2 years after patients completed their reconstruction to only 54 percent at 5 years. This decline in cosmetic outcome was not associated with the type of implant used, the volume of the implant, the age of the patient, or the type of mastectomy incision employed. Radiotherapy was not a significant factor because only 28 patients were irradiated. Upon Cox model analysis, pathological capsular contracture was the only factor that contributed significantly to a poor cosmetic outcome in which p < 0.0001 (relative risk 6.3). Despite a high revisional surgery rate, deterioration still occurred, suggesting that other unaccounted for variables were responsible. On photographic retrospective review of the patients without capsular contracture who demonstrated deterioration in their cosmetic scores, it became clear that a possible reason for their poor results was late asymmetry produced by the failure of both breasts to undergo symmetrical ptosis with aging.

Prospective evaluation of late cosmetic results following breast reconstruction: II. Tram flap reconstruction.

Although it is thought that transverse rectus abdominis muscle (TRAM) flap breast reconstruction produces excellent cosmetic results that are maintained over the long term, there is little objective evidence in the literature to support this. One hundred seventy-one consecutive patients who underwent TRAM flap reconstruction were prospectively analyzed over an 8-year period to assess their morbidity and late cosmetic outcome.The early patient complication rate (< 2 months) was 37.4 percent, the late hernia and fat necrosis rates (> 2 months) were 8.8 and 13.5 percent, respectively, and the contralateral symmetrization rate was 33.9 percent. The cosmetic results were evaluated prospectively using an objective five-point global scale. Each patient was scored at each visit once surgery was completed. Follow-up continued until a flap was lost, a patient died, or the point of last patient contact was reached. Six patients died during the study. The actuarial percentage cosmetic outcome remained stable during the study period, with an acceptable result in 96.4 percent of patients at 2 years and in 94.2 percent of patients at 5 years. Only five patients in this series obtained poor cosmetic outcomes, with three due to substantial flap necrosis and two because of poor flap design. Two free TRAM flaps were also lost. Log-rank analysis revealed that neither patient age nor timing of surgery significantly affected the cosmetic outcome. Single pedicle and supercharged (single pedicle) TRAM flaps produced slightly better results than bipedicle and free TRAM flaps. In this prospective longitudinal study, TRAM flap reconstructions were shown to produce aesthetically pleasing results. Moreover, with long-term follow-up, it was demonstrated that these reconstructions maintained their stability.

[Axillary lymph node surgery in 1998]. / La chirurgie du creux axillaire en 1998.

The need for a systematic axillary clearance in breast cancer is presently under question. Alternative methods include the omission of node biopsy in very small tumours and lymphadenectomy limited to the sentinel node. This article discusses the current procedures in axillary surgery in 1998, with information concerning the relationships between the tumour characteristics and the probability of nodal involvement, the new surgical techniques aiming at reducing morbidity, with special emphasis on sentinel node biopsy, and the therapeutic protocols presently being used at the Institut Curie.

[Analysis of 10 cases of pregnancy after renal transplantation]. / Analyse de 10 cas de grossesse après transplantation rénale.

Renal transplantation has changed completely the fertility of women who had been dialysed. Our study is on 10 pregnancies which we followed up in 7 women who had had renal transplants in the University Hospital of Pitié Salpêtrière (Professor Y. Darbois) between 1979 and 1985. All patients were treated by the same technique and the same methods of prevention of rejection of the transplant. The mean interval between the transplant and pregnancy was 53 months. In 3 cases there was hypertension and raised creatinine levels (more than 150 in 3 cases). In 2 cases the two conditions were associated. The prognosis is bad when a raised blood pressure or a change in renal function occurs before pregnancy starts, leading to a real deterioration in renal function during the pregnancy when such function was abnormal before the pregnancy started. As far as the infants were concerned, the most common complication was IUGR (intrauterine growth retardation) which was found in half of all cases. Blood flow studies in these fetuses are particularity interesting. There were two cases of intra-uterine fetal death. The reasons for these were not necessarily connected with the deterioration in renal function. All the deliveries were by caesarean section, for medical reasons in 7 out of 10 cases. The average duration of the pregnancy was 35 weeks of amenorrhoea. As far as the mothers were concerned, they did not have more infections than other women in spite of being immuno-suppressed (this was excluding urinary tract infections).(ABSTRACT TRUNCATED AT 250 WORDS)

[Analysis of 42 membrane ruptures during the second pregnancy trimester]. / Analyse de 42 ruptures des membranes au deuxième trimestre de la grossesse.

65 cases of premature rupture of the membranes before the 28th week of amenorrhoea occurred during the 5 years between 1983 and 1987 in two maternity units in Paris. A retrospective study was carried out on 42 of these cases where conservative measures had been decided on. In two-thirds of the cases, of which 42% had had bleeding and 40% vaginal infection, the pregnancy had appeared to be progressing normally before the rupture of the membranes. 14% had had cerclage and 12% had had selective intrauterine fetal reduction or biopsy of the trophoblast or removal of an intrauterine device. Rupture of the membranes rarely happens in isolation because it is usually accompanied by uterine contraction or bleeding, which may occur separately or associated with one another in half the cases. In 21% of cases bacteriological examination was positive after the rupture. All patients were treated conservatively in this study. Antibiotics were prescribed in 35 cases and tocolysis in 13 cases. The membranes were ruptured on an average for 7 days. It was almost impossible to avoid infection except in two patients who delivered rapidly. The pregnancies resulted in 8 intrauterine deaths, 15 deliveries of babies that were not viable, 19 deliveries of live babies of which 7 were by caesarean section. 15 babies survived the neonatal period. This work makes it possible to judge whether it is really hazardous to try to be conservative before the 24th week of amenorrhea. Even if neonatal mortality is being lowered at term, overall in our series it was 25%. Finally, it does not seen that tocolytics or antibiotics help to lower this mortality significantly.

[The vaginal cesarean, a necessary review]. / La césarienne vaginale, une nécessaire réhabilitation.

Having carried out four cases of vaginal caesarean section the authors describe the technique they used. The advantages of the operation are: it is simple and can be carried out quickly, future obstetric behaviour is not compromised. It is important to avoid two complications of the operation: haemorrhage and injury to the bladder. These are reduced if the vertical incision in the cervix is made in the midline and long enough. The ideal indications for the operation are absence of cervical dilatation, or the occurrence of severe maternal haemorrhage during the operation to terminate a pregnancy, or while the uterine contents are being expelled towards the end of the second trimester. It is disputable whether there is a place for vaginal caesarean operation when the fetus is alive, in view of the recent studies on fetal prognosis.

Extensive pure ductal carcinoma in situ of the breast: identification of predictors of associated infiltrating carcinoma and lymph node metastasis before immediate reconstructive surgery.

AIM: To identify predictors for infiltrating carcinoma and lymph node involvement, before immediate breast reconstructive surgery, in patients with an initial diagnosis of extensive pure ductal carcinoma in situ of the breast (DCIS). PATIENTS AND METHODS: Between January 2000 and December 2009, 241 patients with pure extensive DCIS in preoperative biopsy had underwent mastectomy. Axillary staging (sentinel node and/or axillary dissection) was performed in 92% (n = 221) of patients. Patients with micro-invasive lesions at initial diagnosis, recurrence or contralateral breast cancer were excluded. RESULTS: Respectively 14% and 21% of patients had a final diagnosis of micro-invasive carcinoma (MIC) and invasive ductal carcinoma (IDC). Univariate analysis showed that the following variables at diagnosis were significantly correlated with the presence of either MIC or IDC in the mastectomy specimen: palpable tumor (p = 0.002), high grade DCIS (p = 0.002) and detection of an opacity by mammography (p = 0.019). Axillary lymph node (ALN) involvement was reported in 9% of patients. Univariate analysis suggested that a body mass index higher than 25 (p = 0.007), a palpable tumor (p = 0.012) and the detection of an opacity by mammography (p = 0.044) were associated with an increased rate of ALN involvement. CONCLUSION: Skin-sparing mastectomy and immediate breast reconstruction (IBRS) has become increasingly popular, especially for patients with extended DCIS of the breast. This study confirmed that extended DCIS is associated with a substantial risk of finding MIC or IDC on the surgical specimen but also ALN involvement. Adjuvant systemic treatment and/or radiotherapy could be indicated for some of these patients after the surgery. Patients should be informed of the rate of 1) complications associated to IBRS that will potentially delay the introduction of systemic or local therapy 2) complications associated to radiotherapy after IBRS.

Monoamines tissue content analysis reveals restricted and site-specific correlations in brain regions involved in cognition.

The dopamine (DA), noradrenalin (NA) and serotonin (5-HT) monoaminergic systems are deeply involved in cognitive processes via their influence on cortical and subcortical regions. The widespread distribution of these monoaminergic networks is one of the main difficulties in analyzing their functions and interactions. To address this complexity, we assessed whether inter-individual differences in monoamine tissue contents of various brain areas could provide information about their functional relationships. We used a sensitive biochemical approach to map endogenous monoamine tissue content in 20 rat brain areas involved in cognition, including 10 cortical areas and examined correlations within and between the monoaminergic systems. Whereas DA content and its respective metabolite largely varied across brain regions, the NA and 5-HT contents were relatively homogenous. As expected, the tissue content varied among individuals. Our analyses revealed a few specific relationships (10%) between the tissue content of each monoamine in paired brain regions and even between monoamines in paired brain regions. The tissue contents of NA, 5-HT and DA were inter-correlated with a high incidence when looking at a specific brain region. Most correlations found between cortical areas were positive while some cortico-subcortical relationships regarding the DA, NA and 5-HT tissue contents were negative, in particular for DA content. In conclusion, this work provides a useful database of the monoamine tissue content in numerous brain regions. It suggests that the regulation of these neuromodulatory systems is achieved mainly at the terminals, and that each of these systems contributes to the regulation of the other two.

Management of exposed, infected implant-based breast reconstruction and strategies for salvage.

INTRODUCTION: Complications of implant-based breast reconstruction are rare but mastectomy flap necrosis and peri-implant infection are the most frequent and remain an important cause of early implant failure. This study aimed to compare the results of three different management strategies employed to deal with these complications at our institution. PATIENTS AND METHODS: A consecutive series of 71 infected/exposed prostheses in 68 patients over a 20-year period were analysed. Management strategies included explantation and delayed reconstruction, implant salvage and explantation and immediate autologous reconstruction. RESULTS: Only 19 of 45 (42%), managed with implant removal, went on to delayed reconstruction. Methods of delayed reconstruction were distributed equally between implant-only, implant and autologous tissue and autologous-only reconstructions. The implant was successfully salvaged in nine cases, but reducing the implant size or introducing new tissue as a flap increased the success from 45% to 53%. Three patients with infected implant-only breast reconstruction underwent explantation and immediate conversion to autologous-only reconstructions. CONCLUSIONS: All the three interventions reviewed here have their place in the management of infected implant-based breast reconstructions. It is noteworthy that following implant removal, the likelihood of the patient proceeding to delayed reconstruction of any kind is similar to the likelihood of successful salvage (42% vs. 45%). This study population had high numbers of exposed implants in irradiated fields. Reducing implant size or introducing new tissue in the form of a flap increases the chances of successful implant salvage. In the presence of mild infection, removal of exposed/infected implants and immediate conversion to an autologous-only reconstruction can prove to be successful.