The Breast-Pectoralis Flap: A New Advance in Autologous Breast Reconstruction-A Preliminary Report on 20 Cases.

BACKGROUND: In the past, several publications have described breast reconstruction techniques that utilize the contralateral breast; however, interest diminished because of technical difficulty, scarring, and poor aesthetic results. OBJECTIVES: This study aimed to present a new breast reconstruction technique that uses a combination of the breast-pectoralis flap and the abdominal advancement flap. METHODS: This retrospective study analyzed the results and complications of 20 consecutive breast reconstructions with the breast-pectoralis flap technique. RESULTS: The authors present a series of 20 breast reconstructions that utilized the breast-pectoralis flap. Delayed breast reconstruction was performed in 13 cases (65%), breast reconstruction in 5 patients (25%) with Poland syndrome, sequela correction after a chest wall sarcoma in 1 patient (5%), and sequela correction after breast cystic lymphangioma resection in 1 patient (5%). One complication required surgical reintervention without long-term consequences. The outcomes were considered very good in 50% of the cases, good in 45%, and fair in 5%. CONCLUSIONS: The combination of the breast-pectoralis flap and the abdominal advancement flap is an interesting advance in breast reconstruction. Evaluation of the presented cases suggests wider indications for this technique.

Comparative Analysis of a New Automatic System and Four Existing Techniques for Autologous Fat Grafting.

Background: Autologous fat grafting is increasingly used worldwide and is a very attractive technique in many ways. However, treatment duration and postinjection tissue resorption remain problematic elements, which are largely related to the preparation method used. Moreover, few scientific studies objectively compare different fat preparation methods. This study analyzes the efficiency and quality of lipoaspirates prepared with a new filtration/centrifugation system (Adipure) in comparison with several existing techniques. Methods: Patient lipoaspirates were processed by five different techniques: decantation, centrifugation, Macrofill, Puregraft, and Adipure. Adipose tissue was evaluated in vitro for tissue resorption and oil formation, as well as in vivo after subcutaneous injections in immunodeficient mice. Adipose grafts were collected after 1 month, weighed, and analyzed by histology with a detailed scoring method. Results: Decanting gives inferior results to all other techniques, in terms of amount of tissue and oil in vitro, or graft weight and histological analysis in vivo. Methods using classical Coleman centrifugation (1200g), or a modified one (400g) associated with washes (Macrofill) produce very similar results, both in vitro and in vivo. Techniques using filtration systems (Puregraft and Adipure) produce less oil overall and have a higher grafting efficiency. The best results regarding grafting efficiency and oil quantity are found with the Adipure device. Conclusions: A combination of filtration and very low-speed centrifugation potentiates the advantages of these techniques, in terms of graft efficiency. The adipose tissue purification being done in a few minutes, in an automatic way, undoubtedly provides a strong advantage for the use of this new system.

Dorsal Lipomodeling to Treat Donor Site After Latissimus Dorsi Flap: Safety and Effectiveness.

BACKGROUND: The latissimus dorsi flap (LDF) is a classic and efficient technique for breast reconstruction. However, its use has recently diminished in surgical practice due to dorsal disadvantages and to the increased use of microsurgical techniques for breast reconstruction, such as the deep inferior epigastric artery perforator flap. OBJECTIVES: The aim of this study was to evaluate the safety and efficacy of managing dorsal problems such as asymmetry, irregularities, and dysesthesia by lipomodeling the back region during the associated surgery for breast reconstruction. METHODS: A series of 300 patients operated by the last author for dorsal lipomodeling to correct sequelae after harvesting the total LDF, between November 2012 and March 2019, was analyzed. RESULTS: The results show a very good improvement in the dorsal region in 6.7% of cases, good improvement in 86.7% cases, and fair improvement in 6.7% of cases. There was a good improvement in dorsal comfort in 90% of cases, a very good improvement in 6.66% of cases, and a fair improvement in 6.66% of cases. In 5% of cases 2 sessions were required to obtain a satisfactory result. No major complications were registered, and the only complication encountered were oil cysts in 2.6% of cases that were treated during consultation with percutaneous puncture. CONCLUSIONS: This study showed that lipomodeling in the back area after LDF harvesting is an efficient and safe technique that corrects secondary dorsal sequelae such as irregularities, asymmetry, sensitivity, and dysesthesia. This technique should increase the indications for LDF because it decreases donor site sequelae, which are some of the main drawbacks of the LDF approach.

An Early Neoplasia Index (ENI10), Based on Molecular Identity of CD10 Cells and Associated Stemness Biomarkers, is a Predictor of Patient Outcome in Many Cancers.

An accurate estimate of patient survival at diagnosis is critical to plan efficient therapeutic options. A simple and multiapplication tool is needed to move forward the precision medicine era. Taking advantage of the broad and high CD10 expression in stem and cancers cells, we evaluated the molecular identity of aggressive cancer cells. We used epithelial primary cells and developed a breast cancer stem cell­based progressive model. The superiority of the early-transformed isolated molecular index was evaluated by large-scale analysis in solid cancers. BMP2-driven cell transformation increases CD10 expression which preserves stemness properties. Our model identified a unique set of 159 genes enriched in G2­M cell-cycle phases and spindle assembly complex. Using samples predisposed to transformation, we confirmed the value of an early neoplasia index associated to CD10 (ENI10) to discriminate premalignant status of a human tissue. Using a stratified Cox model, a large-scale analysis (>10,000 samples, The Cancer Genome Atlas Pan-Cancer) validated a strong risk gradient (HRs reaching HR = 5.15; 95% confidence interval: 4.00­6.64) for high ENI10 levels. Through different databases, Cox regression model analyses highlighted an association between ENI10 and poor progression-free intervals for more than 50% of cancer subtypes tested, and the potential of ENI10 to predict drug efficacy. The ENI10 index constitutes a robust tool to detect pretransformed tissues and identify high-risk patients at diagnosis. Owing to its biological link with refractory cancer stem cells, the ENI10 index constitutes a unique way of identifying effective treatments to improve clinical care. SIGNIFICANCE: We identified a molecular signature called ENI10 which, owing to its biological link with stem cell properties, predicts patient outcome and drugs efficiency in breast and several other cancers. ENI10 should allow early and optimized clinical management of a broad number of cancers, regardless of the stage of tumor progression.

Outcomes of DIEP flap reconstruction after pelvic cancer surgery: A retrospective multicenter case series.

BACKGROUND: Flap reconstruction is often required after pelvic tumor resection to reduce wound complications. The use of perforator flaps has been shown to reduce donor site morbidity. The purpose of this study was to evaluate the outcomes of pedicled deep inferior epigastric perforator (pDIEP) flap reconstruction. METHODS: This was a retrospective multicenter study of patients who underwent immediate pDIEP flap reconstruction for a pelvic or perineal defect after tumor resection between November 2012 and June 2022. The primary outcome was abdominal donor site morbidity, and the secondary outcome was perineal morbidity. RESULTS: Thirty-four patients (median age, 57.5 years) who underwent pelvic exenteration (n = 31), extralevator abdominoperineal excision (n = 2), or extended vaginal hysterectomy (n = 1) were included. The most common indications were recurrent cervical (n = 19) and anal (n = 4) squamous cell carcinoma. Twenty-nine patients (85%) had a history of radiotherapy. Only one patient (3%) had major (Clavien-Dindo ≥ III) donor site complications (surgical site infection due to tumor recurrence). Eleven patients (32%) had at least one major recipient site complication (surgical site infection [n = 1], total [n = 2] or partial [n = 1] flap loss, perineal dehiscence [n = 2], hematoma [n = 1], fistula [n = 5]). No incisional or perineal hernias were observed during follow-up. Ninety-day survival was 100%. CONCLUSION: Pedicled DIEP flap reconstructions performed by experienced surgical teams had good outcomes for perineal or vaginal reconstruction, with low abdominal morbidity, in patients with advanced pelvic malignancies who had undergone median laparotomy. The risks and benefits of this procedure should be carefully evaluated preoperatively using clinical and imaging data.

Short-Scar Latissimus Dorsi With a Lateral Approach: A Game Changer in Breast Reconstruction?

BACKGROUND: In delayed breast reconstruction, the thoraco-mammary cutaneous tissue often shows residual damage from radiotherapy. The fragility of this tissue is associated with a risk of skin necroses of approximately 8% when dissection is performed by reopening of the mastectomy scar. OBJECTIVES: The objective of this study was to adapt the technique of short-scar latissimus dorsi flap surgery with an abdominal advancement flap employing a lateral approach only avoiding re-incision of the mastectomy scar. METHODS: In this retrospective study, the authors performed 150 reconstructions in 146 patients to assess the safety and effectiveness of the short-scar latissimus dorsi technique with lateral approach. The primary outcome was the occurrence of postoperative skin necrosis of the thoraco-mammary area. RESULTS: Of the 150 delayed breast reconstruction procedures performed, none showed skin necrosis of the thoraco-mammary area, and a positive effect on skin trophicity of this area was observed. The resulting patient and surgical team satisfaction were very favorable. CONCLUSIONS: In the authors' practice, this technique changed their paradigm because of good skin safety and effectiveness. It allows reconstruction without a patch-effect in patients with very poor skin quality in whom the thoraco-mammary skin would have been replaced in the past by a skin paddle. Reconstruction would have even be contraindicated. It could also be an alternative to many other more complex and longer techniques of autologous reconstruction.

Lessons Learned From Twenty-Eight Cases of Burns Following Breast Reconstruction: An Underestimated Complication Requiring Inclusion in Consent Information.

BACKGROUND: There has over recent years been a constant increase in annual breast reconstruction figures. Although reports indicate that burns following breast reconstruction are a rare occurrence, there has nevertheless been a relative increase in cases. The key underlying causes of this type of condition remain unknown. OBJECTIVES: The authors launched a new study on the demographic characteristics of burns in the breast reconstruction population with the inclusion of up-to-date data to assess cases and contributing factors. METHODS: The study was a multicenter retrospective review of patients who underwent any type of breast reconstruction and subsequently sustained burn injuries. RESULTS: Twenty-eight cases of burn injury following breast reconstruction were documented; 6 involved autologous flaps and 22 involved implants. Nine of the 10 implant exposure cases had previous history of radiotherapy, but there was no statistically significant difference between previous radiotherapy history and implant exposure (P = 0.32). Of the 13 cases sustaining full-thickness burns, a large number included implant-based reconstruction (n = 12, 92%), although no statistically significant difference was observed between type of reconstruction and incidence of full-thickness burns (P = 0.17). CONCLUSIONS: Each patient undergoing breast reconstruction should be advised of the potential risks and instructed to avoid significant heat exposure and steer clear of dark-colored bathing suits. At the time of writing, this information has yet to be included in the vast majority of surgery-related informed consent documents.

Risk Factors Associated With Complications After Unilateral Immediate Breast Reconstruction: A French Prospective Multicenter Study.

BACKGROUND/AIM: For women who have undergone a mastectomy, breast reconstruction provides psychological as well as aesthetic benefits. Thus, many patients ask for an immediate breast reconstruction (IBR). The present study focuses on risk factors assiociated with complications after IBR. PATIENTS AND METHODS: A national prospective study (2007-2009) was conducted on 404 patients who underwent an unilateral IBR: 205 implants alone (IA) including 46 tissue expanders, 91 latissimus dorsi musculocutaneous flaps with implant (LDI), 78 autologous latissimus dorsi musculocutaneous flaps (LD), and 30 autologous transverse rectus abdominis musculocutaneous flaps (TRAM). Outcomes concerned major and minor complications, as well as early and late complications. RESULTS: Related risks of complications were different according to the IBR technique. Major complications rate remained moderate and concerned 15% of patients. Obesity and diabetes significantly increased the incidence of major complications. CONCLUSION: To reduce complication rate, the risk factors associated with each type of IBR should be taken into account.

Combined therapy for critical limb ischaemia: Biomimetic PLGA microcarriers potentiates the pro-angiogenic effect of adipose tissue stromal vascular fraction cells.

We propose a regenerative solution in the treatment of critical limb ischaemia (CLI). Poly-lactic/glycolic acid microcarriers were prepared and coated with laminin to be sterilized through γ-irradiation of 25 kGy at low temperature. Stromal vascular fraction (SVF) cells were extracted through enzymatic digestion of adipose tissue. Streptozotocin-induced diabetic mice underwent arteriotomy and received an administration of SVF cells combined or not with biomimetic microcarriers. Functional evaluation of the ischaemic limb was then reported, and tissue reperfusion was evaluated through fluorescence molecular tomography. Microcarriers were stable and functional after γ-irradiation until at least 12 months of storage. Mice that received an injection of SVF cells in the ischaemic limb have 22% of supplementary blood supply within this limb 7 days after surgery compared with vehicle, whereas no difference was observed at Day 14. With the combined therapy, the improvement of blood flow is significantly higher compared with vehicle, of about 31% at Day 7 and of about 11% at Day 14. Injection of SVF cells induces a significant 27% decrease of necrosis compared with vehicle. This effect is more important when SVF cells were mixed with biomimetic microcarriers: -37% compared with control. Although SVF cells injection leads to a non-significant 22% proprioception recovery, the combined therapy induces a significant recovery of about 27% compared with vehicle. We show that the combination of SVF cells from adipose tissue with laminin-coated poly-lactic/glycolic acid microcarriers is efficient for critical limb ischaemia therapy in a diabetic mouse model.

Indications and Controversies in Lipofilling for Partial Breast Reconstruction.

The treatment of sequelae after conservative breast cancer treatment can be a challenge. Lipomodeling, although controversial in the beginning, is a safe technique that can help in the treatment of these deformities, without an important impact on the imaging surveillance. Depending on the severity of the deformity, one or several sessions of fat transfer can be required. The technique is easy and reproducible, but before obtaining satisfying results with a low complication rate, a learning curve should be completed. The final result is natural, with normal breast consistency, with no additional scars.

Indications and Controversies in Total Breast Reconstruction with Lipomodeling.

Complete breast reconstruction with fat grafting is an appealing technique because it does not add scars or use flaps, is autologous, and has the secondary benefit of liposuction. It is a multiple stage surgery and usually requires balancing of the contralateral breast. After using this technique since 2001, the authors narrowed the indications, the ideal candidate being a patient with small breasts and enough donor sites for up to 4 or 5 lipomodeling sessions. Breast reconstruction with fat grafting alone in total breast reconstruction has very limited indications, because lipomodeling in combination with other autologous reconstruction gives very nice results.

Skin-Reducing Mastectomy in Immediate Reconstruction: How to Limit Complications and Failures.

BACKGROUND: In hypertrophic and/or very ptotic breasts, skin-reducing mastectomy (SRM) is challenging and the risk of complications is high. Few publications have reported the use of an autologous latissimus dorsi flap (ALDF) in this indication. Most studies opt for implant reconstructions, with a high failure rate. OBJECTIVES: We aimed to identify and present the technical refinements that reduce the risk of reconstruction failure in patients with hypertrophic and/or ptotic breasts with breast cancer or at risk of breast cancer after SRM with immediate breast reconstruction (IBR) utilizing an ALDF. METHODS: Our retrospective study, covering a period of 18 years, included a series of 60 patients with hypertrophic and/or ptotic breasts who underwent 67 SRM and IBR procedures utilizing an ALDF. The complications were recorded and the risk factors analyzed. RESULTS: Sixty-seven SRMs were reviewed. Forty-nine procedures were performed with an inverted-T scar technique and 18 with a vertical scar technique. The nipple-areola complex (NAC) was preserved in 10 cases. There were eight (11.9%) cases of minor mastectomy flap necrosis after skin-reducing reconstructions, 16 (23.8%) wound dehiscences, no infections, no breast seromas, and no reconstruction failures. Smoking increased the risk of minor mastectomy flap necrosis (P = 0.048) and wound dehiscence (P = 0.002). Previous radiotherapy was associated with minor mastectomy flap necrosis (P = 0.001). CONCLUSIONS: The use of an ALDF together with technical refinements that preserve the vascular supply of the skin envelope leads to successful IBR with consistently good aesthetic results. Above all, it avoids failure of the reconstruction in very large or ptotic breasts.

Long-term exposure to bisphenol A or benzo(a)pyrene alters the fate of human mammary epithelial stem cells in response to BMP2 and BMP4, by pre-activating BMP signaling.

Bone morphogenetic protein 2 (BMP2) and BMP4 are key regulators of the fate and differentiation of human mammary epithelial stem cells (SCs), as well as of their niches, and are involved in breast cancer development. We established that MCF10A immature mammary epithelial cells reliably reproduce the BMP response that we previously identified in human primary epithelial SCs. In this model, we observed that BMP2 promotes luminal progenitor commitment and expansion, whereas BMP4 prevents lineage differentiation. Environmental pollutants are known to promote cancer development, possibly by providing cells with stem-like features and by modifying their niches. Bisphenols, in particular, were shown to increase the risk of developing breast cancer. Here, we demonstrate that chronic exposure to low doses of bisphenol A (BPA) or benzo(a)pyrene (B(a)P) alone has little effect on SCs properties of MCF10A cells. Conversely, we show that this exposure affects the response of immature epithelial cells to BMP2 and BMP4. Furthermore, the modifications triggered in MCF10A cells on exposure to pollutants appeared to be predominantly mediated by altering the expression and localization of type-1 receptors and by pre-activating BMP signaling, through the phosphorylation of small mothers against decapentaplegic 1/5/8 (SMAD1/5/8). By analyzing stem and progenitor properties, we reveal that BPA prevents the maintenance of SC features prompted by BMP4, whereas promoting cell differentiation towards a myoepithelial phenotype. Inversely, B(a)P prevents BMP2-mediated luminal progenitor commitment and expansion, leading to the retention of stem-like properties. Overall, our data indicate that BPA and B(a)P distinctly alter the fate and differentiation potential of mammary epithelial SCs by modulating BMP signaling.

Quantifying Epithelial Early Common Progenitors from Long-Term Primary or Cell Line Sphere Culture.

Here, a protocol to quantify epithelial early common progenitor/stem cells grown as spheres in non-adherent culture conditions is described. This protocol is based on the combination of two functional tests: the sphere assay to maintain and enrich early progenitor/stem cells, and the epithelial colony-forming cells (E-CFC) assay to identify and quantify further differentiated epithelial progenitors. Primary spheres mainly contain progenitors and rare stem/early common progenitor cells while secondary and tertiary spheres contain progenitor cells derived from the early common progenitor/stem cell population maintained through passages and partially differentiated. Spheres are enzymatically and mechanically dissociated; the derived cells are subsequently plated on irradiated NIH-3T3 fibroblasts for further processing, as in the E-CFC assay. The principle of this assay is to quantify the number of epithelial colonies generated by cells present in the different sequential spheres. This assay has therefore been named the early common progenitor-derived colonies assay (ECP-DC).

The Role of Fat Grafting in Breast Reconstruction.

Breast lipomodeling, or breast fat grafting, is a major development in breast plastic surgery. This technique has a low complication rate, excellent results, and patient acceptance. Radiologic evaluation mostly shows a normal-appearing breast. During breast reconstruction, fat grafting is the ideal complement of the latissimus dorsi flap. Fat grafting for Poland syndrome seems to be a great step and will most likely drastically change the surgical treatment of severe cases. Finally, lipomodeling is a new alternative in the treatment of pectus excavatum, tuberous breasts, and breast asymmetries.

Disequilibrium of BMP2 levels in the breast stem cell niche launches epithelial transformation by overamplifying BMPR1B cell response.

Understanding the mechanisms of cancer initiation will help to prevent and manage the disease. At present, the role of the breast microenvironment in transformation remains unknown. As BMP2 and BMP4 are important regulators of stem cells and their niches in many tissues, we investigated their function in early phases of breast cancer. BMP2 production by tumor microenvironment appeared to be specifically upregulated in luminal tumors. Chronic exposure of immature human mammary epithelial cells to high BMP2 levels initiated transformation toward a luminal tumor-like phenotype, mediated by the receptor BMPR1B. Under physiological conditions, BMP2 controlled the maintenance and differentiation of early luminal progenitors, while BMP4 acted on stem cells/myoepithelial progenitors. Our data also suggest that microenvironment-induced overexpression of BMP2 may result from carcinogenic exposure. We reveal a role for BMP2 and the breast microenvironment in the initiation of stem cell transformation, thus providing insight into the etiology of luminal breast cancer.

Pyoderma gangrenosum: an exceptional complication of venous access device.

INTRODUCTION: Pyoderma gangrenosum (PG) is a rare disease whose precise etiology remains unknown. It causes rapidly developing skin necrosis and can occur after surgery, or after a nonspecific external stimulus. This condition is difficult to diagnose because it often mimics a fulminant infection. CLINICAL CASE: We present a case of very significant local presentation of PG after placement of a venous access device. Fifteen days after placement, the patient developed extensive cutaneous ulcers and necrosis in the subclavicular area, which led to the misdiagnosis of infection. The device was removed and the patient was given antibiotics. Because there was no improvement following antibiotic treatment, combined with the worrying and extensive appearance of the skin and extremely intense pain, the diagnosis of PG was made. The patient was immediately treated with high-dose corticosteroids, resulting in rapid improvement of the lesions and relief of pain. CONCLUSION: PG should be considered in cases of extensive, antibiotic-resistant ulceration and treatment with corticosteroids should be initiated. Clinical improvement is usually dramatic, with almost immediate suppression of the pain and arrest of the lesion's progression. Early treatment is the best guarantee for an effective recovery.

Percutaneous fasciotomies and fat grafting: indications for breast surgery.

BACKGROUND: The management of breast deformities can be very difficult in the presence of breast shape retraction. Percutaneous fasciotomies, which release fibrous strings, can be a very useful tool for shape improvement in the recipient site for a fat graft. OBJECTIVES: The authors evaluate the efficacy of fasciotomies in association with fat grafting in breast surgery. METHODS: A retrospective chart review was conducted for 1000 patients treated with concurrent fasciotomies and fat grafting between January 2006 and December 2011. The recipient site was prepared with fasciotomies, and fat was harvested from other parts of the body using a low-pressure 10-mL syringe lipoaspiration system. Fat was centrifuged and injected into the breast for reconstruction or chest deformities. The postoperative appearance of the breast scars was scored by both the surgeon and the patient. Each complication was recorded, including instances of hematoma, infection, tissue wounds, scar healing, and fat necrosis. RESULTS: In this series of patients, for whom the primary indications for the procedure were sequelae of breast-conserving surgery after cancer, latissimus dorsi flap breast reconstruction, breast implant reconstruction, tuberous breast, Poland syndrome, and funnel chest, we recorded the following complications: 0.8% local infections (8/1000), 0.1% delayed wound healing that required medical care (1/1000), and 3% fat necrosis (31/1000). Fasciotomy scarring was considered minor by the patient in 98.5% of cases and by the surgeon in 99% of cases at 1 year postoperatively. CONCLUSIONS: Fat grafting is a safe and reliable technique that improves the aesthetic outcomes of breast surgery. Percutaneous fasciotomies provide excellent aesthetic results and an improvement in breast shape with no scarring. In our experience, both fat grafting and fasciotomies offer a durable result over the long term.

Breast asymmetry and pectus excavatum improvement with fat grafting.

BACKGROUND: In women, pectus excavatum malformation can cause modified breast morphology, resulting in mammary asymmetry, which can be increased by placing mammary implants alone. Fat transfer can be an elegant solution to increase the volume and projection of the breast. OBJECTIVES: The authors discuss their experience treating pectus excavatum with fat transfer (lipomodeling) since 2000. METHODS: The charts of 19 consecutive patients with a pectus excavatum breast asymmetry who underwent lipomodeling treatment at the authors' facility between January 2000 and November 2011 were retrospectively reviewed. Patients were separated using the Chin classification (type 1, 2, and 3). Data points for each patient included age and body mass index, number of interventions and volume of fat injected during each session, total volume transferred, and postoperative complications. The clinical result was evaluated by the patient and the surgical team on a 4-point scale: very good, good, fair, or poor. RESULTS: Most (74%) patients in this series had type 3 Chin pectus excavatum. The average age was 28 years, and the average body mass index was 20.3. The average number of lipomodeling sessions was 1.63, and the average volume of fat transferred was 230 mL per session and 375 mL total. The patients and the surgical team were very satisfied or satisfied in 95% of cases and considered the result fair in 5% of cases. There were no complications. CONCLUSIONS: Fat transfer for treatment of pectus excavatum yields very good (natural and stable) results and high patient satisfaction rates, which makes this technique our preferred method for treating thoracomammary malformations in pectus excavatum.