[Prevention of seroma by quilting suture after harvesting latissimus dorsi flap. The "Chippendale" technic]. / Efficacité du capitonnage dans la prévention du sérome après lambeau de grand dorsal. La technique de << Chippendale >>.

UNLABELLED: Seroma is the most frequent minor complication after harvesting latissimus dorsi flap for breast reconstruction. It induces patient's discomfort and multiple consultations for punctions. The dead space resulting from the harvest has to be closed by the "quilting suture" in order to prevent the seroma. Our aim is to evaluate the efficiency and the tolerance of the quilting suture by comparing two groups of 100 patients who had a breast reconstruction by the same technic of extended latissimus dorsi flap, performed by the same surgeon, from 2004 to 2007. Half of patients had the classic way of dorsal closure, and the other half of patients had the dorsal quilting suture. PATIENTS AND METHODS: In order to compare the two groups we have collected data concerning age, body mass index (BMI), tobacco use, postoperative complications, number and volume of punctions, draining time and postoperative pain. The efficiency of the quilting suture lies on a rigorous repartition of at least six sutures on the upper skin flap, 12 on the lower skin flap and under the skin suture line. The suture model is based on the one used for the Chippendale-designed sofa. We suture the skin flap while pushing down the shoulder, in order to split the skin tension and avoid traction on the final skin suture line. The procedure takes 15 minutes. RESULTS: The "Chippendale" technic allows to reduce draining time from 12 days to 6 days. The incidence of chronic seroma is reduced by 50%. The dorsal wound healing seems also better thanks to tension reduction resulting from the quilting suture. CONCLUSION: The "Chippendale" technic is a quick, cheap and easy learned procedure, efficient for preventing chronic seroma after the latissimus dorsi flap. The postoperative recovery is eased and the patients comforted.

[Treatment by fat tissue transfer for radiation injury in childhood facial cancer]. / Traitement par transfert graisseux des séquelles postradiques de tumeur faciale maligne de l'enfance.

The radiation treatment of malignant facial tumors in children may induce major functional and cosmetic sequelae, mainly due to uneven growth of the bones and soft tissues, resulting in facial asymmetry and hemihypotrophy at adult age. Although fat transfer has proven effective for facial cosmetic treatment, few studies have demonstrated the benefit of the technique in heavily irradiated tissues. The techniques generally used for the treatment of facial asymmetry or hypotrophy are ill-adapted to irradiated patients. Indeed, procedures such as skin detachment, osteotomy and vascular suture are risky because of radiation-induced damage. The aim of the present study was to investigate the potential benefits of fat transfer for the correction of sequelae of facial irradiation. Four patients (two males and two females) aged 27, 25, 16 and 13 years underwent fat grafting for the correction of facial asymmetry or hypotrophy induced by cancer radiation treatment during childhood (radiation dose of more than 50Gy). One to three grafting sessions were required, depending on the cases. After a median follow-up of 3.9 years, cosmetic results were considered satisfactory by both the patient and the surgeon in all four cases. Fat transfer remarkably improved the cosmetic appearance of the patients, without deleterious consequences for the vitality of tissues. In addition, a restoration of skin trophicity was observed, thus confirming the benefit of grafting adipocytes into the irradiated integument. In conclusion, fat grafting appears to be a simple and easily reusable technique which makes it possible to obtain the best morphological and cosmetic results in irradiated patients, whereas avoiding complex and potentially hazardous procedures.

[Breast volume reconstruction by lipomodeling technique: about 15 consecutive cases]. / Reconstruction mammaire par transfert graisseux exclusif: à propos de 15 cas consécutifs.

UNLABELLED: BACKGROUND OF STUDY: The purpose of this prospective study is to detail the preliminary results, the advantages and drawbacks of a new iterative fat transfer protocol in selected breast reconstructions. MATERIAL AND METHODS: Fifteen patients had breast reconstruction following mastectomy for breast cancer by this iterative lipomodeling protocol, between 2002 and 2007. Clinical and technical aspects are described. Indications, advantages, drawbacks, complications and morphological results are discussed. RESULTS: Mean age at first stage procedure was 50 years (min: 41, max: 57). Indications were eight delayed breast reconstructions, three salvage reconstructions after flap failure, two restorations following primary chest wall reconstruction, two immediate breast reconstructions. Two to five sequential procedures were necessary to obtain a satisfactory breast volume (mean: three procedures). Mean total transferred fat volume was 600 cm(3) (min: 266 cm(3), max: 926 cm(3)). Multiple procedures were performed: restoration of breast skin envelope by abdominal advancement fasciocutaneous flap, breast contours liposuction, controlateral breast symmetrisation, nipple areola complex reconstruction. Mean follow-up was 28 months. The aesthetics results have been judged as very good in 10 patients, good in four patients and poor in one patient. The satisfaction rate of the patients is high: 10 patients are pleased, four patients are satisfied and one patient is moderately satisfied. CONCLUSION: Fat transfer alone can efficiently restore breast volume after mastectomy, granting all advantages related with autologous reconstruction. No donor site morbidity is present; in fact some secondary benefits are observed thanks to the correction of eventual disgraceful lipodystrophies. These secondary benefits strengthen patient compliance improving iterative procedures tolerance. Lack of available adipose tissue and high breast volume are the major morphological limits of the technique. In our experience, fat transfer appears to be a promising technique for breast reconstruction. Long term results still have to be evaluated before it can become a standard.

[Skin-sparing mastectomies: how to avoid skin necrosis?]. / Mastectomies avec conservation de l'étui cutané : comment éviter les souffrances cutanées ?

Skin-sparing mastectomy (SSM) has emerged as the surgical technique best adapted to the treatment of early breast cancers or breast cancer recurrences after conservative treatment; the technique is particularly appreciated by the patients who had been expecting the development of immediate, high-quality breast reconstruction for over 15 years. SSM preserves anatomical landmarks on the skin surface (notably the under-breast fold and the conical shape of the breast). The procedure must be performed by a skilled surgical team in order to maximize the quality of breast resection and reconstruction, particularly to avoid postoperative complications, notably damage to blood vessels within the skin flap and prosthesis infection. These complications generally affect the cosmetic outcome of the reconstruction, with serious short-term and long-term consequences for the acceptability of the surgical procedure, and may sometimes compromise the delivery of adjuvant treatments (either chemo- or radiotherapy). Based on our previous experience (1000 new cases since 1992), we will compare the advantages and drawbacks of the procedure, discuss its indications, describe the clinical situations encountered and the various specific interventions available, as well as the methods to reduce the risks of tissue damage and skin necrosis.

[Extra-abdominal desmoid tumor in a scar of donor-site of a latissimus dorsi flap: case report]. / Tumeur desmoïde extra-abdominale survenue sur cicatrice de prélèvement de lambeau de grand dorsal: à propos d'un cas.

Tumefaction arising lately after latissimus dorsi flap harvest are rare and observed in 1 or 2% of the cases. These lesions are frequently related to kystic sero-hematoma and are easily and efficiently treated with surgical excision. In some rare circumstances, a tumoral evolution can mimic a kystic sero-hematoma. We will discuss one case of desmoid tumor arising from a latissimus dorsi flap donor-site scar. The subject was a 45 years old woman who had a breast reconstruction following mastectomy. A dorsal tumefaction, with a benign aspect, was observed during the follow-up period. The biopsy showed an extra-abdominal desmoid tumor. The patient was treated with a large excision of the lesion and reconstructed using two opposing local cutaneous advancing flaps. No radicalization was necessary. No sign of recurrence has been observed at 4 years follow-up.

[Radiological evaluation after lipomodelling for correction of breast conservative treatment sequelae]. / Aspects radiologiques des seins traités par lipomodelage après séquelles du traitement conservateur du cancer du sein.

Breast lipomodelling has been used in our unit since 2002 to correct the sequelae of conservative treatment of cancer. Morphologically, satisfactory results have been recorded and the method is likely to develop considerably. However, the technique has also been questioned because of the possible deleterious radiological impact of injecting fat into the breast. The present work investigated the radiological aspect of conserved breast reconstructed by lipomodelling in a series of 21 patients undergoing ultrasound examination, mammography and MRI, before and after the procedure. Benign-looking microcalcifications were detected on 19% of the mammographies, small (<1cm) oily cysts and complex cysts were visible on respectively 57 and 19% of ultrasound images, whereas 47% of the MRI scans indicated cytosteatonecrotic lesions. Even though multiple events could be observed, their frequency is close to that observed following other conventional breast surgery. Besides, there is clear radiological evidence of benignity. The conclusion of the study is that images obtained after lipomodelling are satisfactory and in no way suggestive of recurrence of breast cancer. Provided that radiologists and experts are aware of this pattern, there is no impact on the radiological follow-up of the patients.

[Efficacy of lipomodelling for the management of sequelae of breast cancer conservative treatment]. / Efficacité du lipomodelage pour la correction des séquelles du traitement conservateur du cancer du sein.

We report a study of 42 breast cancer patients undergoing lipomodelling, or fat transfer, for sequelae of conservative treatment. Detailed clinical and radiological data of the patients have been collected. These data demonstrate the feasibility of lipomodelling: the technique is simple but requires a learning curve to avoid cytosteatonecrotic lesions; the excellent results obtained in terms of shape and softness of the breast; no surgical implant or flap reconstruction is necessary; the reliability of the procedure: there is normal fat wasting within the first months after treatment, then results stabilize as the patient maintains a healthy weight; the small number of side-effects: only rare, predominantly infectious, rapidly resolving complications are induced. In conclusion, the fat transfer approach presented here represents a considerable advance for the management of moderate sequelae of conservative breast treatment. Using this technique makes it possible to restore the shape and softness of the breast better than any other surgical procedure before, particularly for patients with mild breast deformity.

[Post-treatment sequelae after breast cancer conservative surgery]. / Séquelles thérapeutiques du sein après traitement conservateur du cancer du sein.

Thanks to the earlier detection of breast cancer, the advent of neoadjuvant therapy and the development of more effective surgical procedures reducing treatment sequelae, conservative treatment has dramatically expanded over the past 15 years. Several factors have recognized negative aesthetic consequences for breast cancer patients: being overweight, having voluminous or on the contrary, very small breasts, having a tumor located in the lower quadrant, having high breast-tumor: breast-volume ratio. Tissue injuries induced by radiotherapy and chemotherapy, such as shrinking, fibrosis or induration, maximize the deleterious impact of surgery. The results of conservative treatment also deteriorate with time: weight gain is common and may result in increased breast asymmetry. Patients undergoing conservative treatment may experience sequelae including various degrees of the following dimorphisms, all possibly responsible for minor or even major breast deformity: breast asymmetry, loss of the nipple/areola complex, scar shrinkage and skin impairment, irregular shape and position of the nipple and areola. Various sensory symptoms have also been reported following conservative treatment, with patients complaining of hypo- or dysesthesia or even suffering actual pain. Breast lymphedema is also a common incapacitating after-effect that is believed to be largely underdiagnosed in clinical practice. Finally, like mastectomy, conservative breast surgery may induce serious psychological distress in patients who suffer the loss of physical integrity, womanhood or sexual arousal. Clinicians must be aware of the radiological changes indicative of late cancer recurrence. There are four types of modifications as follows: increased breast density, architectural distortion at the surgical site and formation of scar, mammary fat necrosis, and occurrence of microcalcifications. The management of sequelae of conservative breast treatment must therefore involve a multidisciplinary approach; patients not only expect better cosmetic appearance, but also a focus on other treatment advances such as improvement of psychological and sensory outcome. The interpretation of radiological images is also an integral part of the management of these patients at significant risk of recurrence.

[Modified Texier mediodorsal transposition island skin flap of the nose. Report of four cases of ala nasi reconstruction]. / Lambeau médiodorsal du nez de transposition en îlot cutané de Texier modifié. A propos de quatre cas de réparations alaires.

First described by Texier in 1994, the mediodorsal transposition flap of the nose is an island flap. The paramedian dorsal arteries (anastomosed to the interdomal plexus) ensured the axial vascularisation in SMAS plane. The authors will discuss their personal approach to the surgical procedure for the improvement of final result, with four clinical cases. This flap can be used for aesthetic unit reconstruction of cutaneous or mucosal different alar defect (partial or complete, full-thickness or not). This reliable flap represents an alternative technique of composed grafts, of different nasolabial flaps, and of forehead flap.

[Anaplastic thyroid carcinoma: aggressive radical resection and cervical reconstruction. A case report]. / Chirurgie d'exérèse élargie et reconstruction cervicale pour cancer anaplasique de la thyroïde. A propos d'un cas.

STUDY AIM: Anaplastic carcinoma of the thyroid is a rare but highly malignant tumor. The goal of this study was to present the case of a patient who underwent a multimodal treatment and to analyze prognosis factors. PATIENT AND METHODS: We present the case of a patient treated in 1996 for an anaplasic thyroid carcinoma with cervical cutaneous invasion. The initial surgical procedure was a total thyroidectomy extended to the anterior cervical skin associated to bilateral neck dissection. The patient underwent a differed reconstruction with musculocutaneous latissimus dorsi flap. Management was then supplemented by radiotherapy and chemotherapy. RESULTS: This patient is free of tumor 9 years after this multimodal management. She does not present any functionary sequela and plastic results of the reconstruction is considered as very satisfactory. CONCLUSION: Anaplastic carcinoma is one of more aggressive neoplasm affecting humans. This case report suggests that multimodality therapy, including surgery, chemotherapy and radiotherapy may offer hope for long-term survival. A musculocutaneous latissimus dorsi flap is a reliable solution to cover this large cervical defect.

[Bilateral breast reconstruction with the autologous latissimus dorsi flap (a retrospective study of 31 consecutive cases)]. / Reconstruction mammaire bilatérale par lambeau myocutanéograisseux de grand dorsal (31 cas consécutifs).

PURPOSE OF THE STUDY: The purpose of this study was to analyse the advantages, disadvantages and results of bilateral breast reconstruction by autologous latissimus dorsi flap. MATERIAL AND METHOD: Thirty-one two-stage consecutive bilateral breast reconstructions were performed by the same operator between 1993 and 2001. All the reconstructions, in immediate or delayed manner, were indicated after radical or skin sparing mastectomy for breast cancer. We used the autologous latissimus dorsi flap for all cases. The reconstruction of the second breast was always delayed of a few months to avoid back's complications. We reviewed the charts of these patients retrospectively. Preoperative data, postoperative complications, dorsal seroma occurrence, morphological results and patient's satisfaction were evaluated. Median follow-up was 22 months. RESULTS: The results confirm the procedure's reliability. Comparative rates of postoperative complications are not significantly different between first and contralateral breast reconstruction. Functional after-effects of bilateral latissimus dorsi harvesting are moderate. The aesthetics results have been judged as very good in 84% of cases and good in 16%. The satisfaction rate of the patients is high: 90,3% are pleased, 6,5% are satisfied and 3,2% are moderately satisfied. CONCLUSION: The autologous latissimus dorsi flap allows a two-stage bilateral breast reconstruction. This procedure is not indicated for simultaneous bilateral breast reconstruction; it is the main drawback of this technique. So we believe that this procedure is an excellent alternative in all the indications of sequential bilateral breast reconstructions.

[Radiological evaluation of breasts reconstructed with lipomodeling]. / Evaluation radiologique des seins reconstruits ayant bénéficié d'un lipomodelage.

We have been using the lipomodeling technique since 1999 in order to improve the form and the volume of the breasts reconstructed with latissimus dorsi flap. During several recent years this technique has known a considerable development and its results are quite attractive. At the same time, the breast imaging remains to be a fundamental mean of cancer control. The knowledge of radiological manifestations of the implanted fat tissue is very important. The aim of this study was to evaluate the imaging aspects of lipomodeling in breasts reconstructed with latissimus dorsi flap, using three types of explorations: ultrasound, radiological mammography and MRI. A total of 30 patients were included into the study with average age of 51 years. All of these patients underwent a breast reconstruction using a latissimus dorsi flap with lipomodeling, which average volume reached 165 cc. Four of the patient had a bilateral breast reconstruction. Three modes of imaging (ultrasound, mammography and MRI) were performed a year after the surgery. In 20 patients the imaging findings proved to be normal (in total 34 breasts). An image of fat tissue was revealed in 14 cases and some benign microcalcifications were found in 4 patients. A suspicious tissular image was discovered in one patient, who later underwent a biopsy. The result was a benign giant cell granuloma. In conclusion, the lipomodeling technique does not affect the postoperative follow-up of the patients with breast cancer and an imaging controlled biopsy is possible in case of any doubt. At present, some additional studies are underway evaluating the fat tissue transplants in normal breasts, in order to widen its indications in the plastic breast surgery.

[Information of the patient: the characteristics of implant breast augmentation]. / Information de la patiente: les particularités de l'augmentation mammaire par prothèse.

Delivering full information and obtaining enlightened assent is an unavoidable stage before each operation. This paper presents the different "rules" that defines this information duty in France. The assimilation of these different elements: sources, contents and the weight of the information can help the surgeon to carry out the consultation before breast augmentation with more efficiency and objectivity. This preoperative consultation can be divided into 10 steps. Each step is submitted to specific directives, which will depend on the scientific, the law, and the jurisprudence evolution. Therefore, in addition to this article, one can find the new information card concerning implant breast augmentation of the French society of plastic reconstructive and aesthetic surgery. This card is the first update of the previous information cards published in 2002. This card guarantees clear, simple and complete information being a base for information duty.

[Breast implant alternatives]. / Alternatives aux prothèses mammaires.

The use of implants is a basic technique in breast reconstruction after mastectomy, for the correction of breast abnormalities or even more in aesthetic breast augmentation. However, especially in difficult cases, implants can have inconveniences and insufficiencies (poor natural aspect, necessity of replacement, capsular contracture). To mitigate these, numerous alternatives were developed. These autologous techniques use mainly the pedicled or free musculocutaneous flaps, which were at first used in breast reconstruction. Their indications were then widened in surgery of breast abnormalities and in aesthetic surgery of the breast. Main alternatives, described, in the breast implants are envisaged by clarifying their advantages, inconveniences, indications and contraindications. The current place of the fat grafting in breast plastic surgery is defined by taking into account the most recent data.

[3D evaluation and mammary augmentation surgery]. / Apport de l'imagerie tridimensionnelle à la chirurgie d'augmentation mammaire.

The medical application of the interferometry is valid now. The breast surgery works on the shape and the volume of the tissue. The Inspeck technology is now available and works well in our medical practice. The measurement tools for the lengths, euclidian or projected on surface are working well with the same precision of a manual measurement. The estimation of the volume needs to follow exactly the same procedure to get some good results. The virtual breast modification doesn't work anymore with a scientific precision and does not allowed yet an office use. A development of the software is necessary to use all these data enclosed in the 3D models.

[3 D evaluation and breast plastic surgery: preliminary study]. / Apport de l'imagerie 3D à la chirurgie mammaire: étude préliminaire.

Due to the development of the invasive technique of digital exam, the three-dimensional results are more and more precise, spectacular and helpful. The 3D surfacic model is for a medical approach and non invasive. Early in 2003, we have started a patient evaluation before and after surgery. The most common surgical techniques from the breast reconstruction to the breast augmentation and the lipomodeling have been analyzed. This preliminary study has shown objectively some surgical rules and volumetric results. Those results are the elements of the future development of the 3D surfacic model in plastic surgery.

[An unusual risk of liposuction: liposuction of a malignant tumor. About 2 patients]. / Un risque inhabituel de la liposuccion: la liposuccion d'une tumeur maligne. A propos de 2 cas.

Liposuction is a simple and elegant way to treat fatty excess; it has been even used for the treatment of lipomas and some gynecomasties. The goal of this article is to present 2 patients with an unusual complication of this use: the liposuction of a malignant tumor. The first patient consulted following the liposuction of a "gynecomasty", which was in fact a breast cancer. The second was treated by liposuction for an ankle "lipoma"; it proved to be a liposarcoma. In order to avoid liposuction and dissemination of a malignant tumor, the pre-operative investigations have to search clinical peculiarities evoking the diagnosis: an unilateral "gynecomasty", irregular, hard or painless, in a 50-years-old patient, must incite the surgeon to perform a classical excision, just as a recurrent "lipoma", deeply located, voluminous or quickly extensive, situated on the limbs or in the humeroscapular area. Paraclinic investigations may be indicated; doubtful cases must be right away rejected for liposuction, and treated by a surgical excision with strict safety margins and complete anatomopathologic examination of the lesion. Liposuction has become a very useful technique for the plastic surgeon; however, we must not forget, despite of its many advantages the risk for dissemination of an unknown malignant tumor. Every surgeon must keep it in mind and prefer a surgical removal in atypical cases.

[Sports and facial injuries. Feasibility and limitations of an epidemiologic study]. / Sports et traumatismes faciaux. Tentative et limites d'une étude épidémiologique.

Our aim was to conduct an epidemiological study in order to better assess the frequency of maxillo-facial sport injuries. Only those activities that are practised within a sport or game association are included in the study. A standard letter was sent to all French sport and game associations (Olympic or not) as well as to some major insurance companies (73 sport and game associations and 11 insurance companies). However the scope of the study rapidly proved limited since over the two-month period considered only 16 sport associations and one insurance company returned an answer. The exploitable results are presented and a brief overview of the recent relevant international studies is given.

Determination of iodine and bromine in plasma and urine by inductively coupled plasma mass spectrometry.

The simultaneous determination of iodine and bromine in plasma and urine by inductively coupled plasma mass spectrometry, using a Nermag prototype instrument, is described. The sample preparation involves only a 10-fold dilution with a diluent containing europium as an internal standard followed by direct nebulisation in the plasma. The iodine, bromine and europium ions are measured at m/z = 127, 79, and 153, respectively. The sensitivity of the method, with detection limits of 1.6 and 52 micrograms l-1 for iodine and bromine, respectively, is satisfactory for clinical applications. The calibration graphs were linear over the ranges 0-400 micrograms l-1 and 0-40 mg l-1 for iodine and bromine, respectively, which are wide enough for most assays. The recoveries were close to 100% with coefficients of variation of less than 3%. The within-day and between-day reproducibility was about 5%. The concentrations of iodine and bromine in the plasma of 26 healthy individuals were 58 +/- 12 micrograms l-1 and 4.1 +/- 0.9 mg l-1, respectively. The amounts of iodine and bromine eliminated in urine were 94 +/- 97 micrograms per 24 h (range 27-403 micrograms per 24 h) and 3.6 +/- 1.7 mg per 24 h, respectively. These results are in agreement with reported values.