[Modalities for the functionning of a Care Center for women at high risk for breast and ovarian cancers: The French experience of Tenon Hospital]. / Modalités de fonctionnement d'un centre de suivi des femmes à haut risque de cancer du sein et de l'ovaire : une expérience à l'hôpital Tenon.

High risk may be defined as either an absolute risk greater than 20 % or a relative risk greater than 4. Concerning breast and ovarian cancer, high risk patients include carriers of a constitutive deleterious mutation of BRCA1 or BRCA2 genes, patients with a significant family history of breast or ovarian cancer, and patients who have been diagnosed a benign breast lesion with a high risk of degeneration, i.e. atypical hyperplasia. Following up such patients relies on specific strategies. A center including a large panel of physicians involved in the various modalities for patients' management (geneticians, radiologists, gynecologists, plastic surgeons, pathologists, endocrinologists, psychologists, medical oncologists) has been created at Tenon Hospital with this purpose. The collaboration of these different specialists with the referent physician of the patient allows for the definition and the implementation of a patient-centered follow-up continuously updated to take into account the different periods of a woman's life, according to best practices recommendations and the evolving state-of-the art.

[Oblique latissimus dorsi myocutaneous flap in breast reconstruction]. / Le lambeau de grand dorsal à palette oblique en bas et en avant en chirurgie reconstructrice mammaire.

Breast reconstruction with latissimus dorsi myocutaneous flap is a reliable technique. Its width is limited to between 10 and 12 cm if direct closure of the donor site defect is required. We report a study with assessment of the dorsal skin laxity in 25 women, simulating vertical, horizontal and reverse oblique flap. The average width was 12.5 cm (11.6 to 14 cm) for reverse oblique flap, 9.4 cm (8 to 11 cm) for vertical and 9.2 cm (8 to 10.6 cm) for horizontal flap. Our study suggests that the reverse-oblique flap provides a wider flap and reduces the donor site morbidity.

[Complete chest wall reconstruction after en bloc excisions with Gore-Tex/Marlex/Flap sandwich. A retrospective study of 14 cases]. / Reconstruction des pertes de substance totales transfixiantes du thorax par combinaison Gore-Tex/Marlex/lambeau musculocutané. Etude rétrospective de 14 cas.

To assess the results of surgical resection and chest wall reconstruction we reviewed our experience with the complete chest wall reconstruction after en bloc excisions according to an original algorithm based on the location of the thoracic defect. The 14 reconstructions were performed by the senior author. We found 5 central, 6 lateral and 3 borders locations. In the central locations with a total resection of the sternum the reconstruction was realized by Gore-tex's mesh in depth, metal hooks (staples) and Marlex's mesh under a musculocutaneous flap of coverage. In case of lateral location the reconstruction was realized by Gore-tex's mesh covered with a musculocutaneous flap, the borders locations were reconstructed by Marlex's mesh and flap of coverage. The histological diagnoses were: one desmoid tumor, eight sarcomas, a recurrence of hepatocarcinoma and four recurrences of breast cancer. The superficial coverage performed by latissimus dorsis flap 12 for cases and rectus abdominis flap for two cases. All the patients were able to produce a spontaneous breath after surgery. Two deaths at distance and an infection were to regret. On the whole the algorithm of reconstruction according to the location of the defect allows a simplification of the indications.

[The second chart. A retrospective critical analysis of hospital stays of long duration in a public plastic surgery department]. / Le signe de la deuxième pancarte: analyse rétrospective critique des hospitalisations de longue durée dans un service hospitalier de chirurgie plastique.

A nine-month retrospective survey related to the long-duration hospital stays was carried out in our plastic surgery department. Twenty five patients were concerned by a more than 21 days hospitalization, the sum of which reached 1,098 days. These figures corresponded to 1.4% of the patients and 14.5% of the hospitalization days. A critical analysis was based on four principles: 1--a plastic surgery department is exclusively devoted to plastic surgery, 2--nursing cares required by the healing of a soft tissues defect don't usually need hospitalization, 3--even if it has a wide surface and/or if it is located on the lower limbs, a skin graft doesn't usually require more than ten days of hospitalization, 4--without complications, a free tissue transfer doesn't usually require more than 15 days of hospitalization. Application of these principles showed that 633 days (58%) could have been theoretically spared. Consequently, it could have permitted to treat a greater number of patients. The cause of delaying patient exit was related to the surgeon in all but one cases. It was associated in 16% of cases with a bed shortage in the convalescent or nursing homes. As hospitalization durations longer than 25 days seemed unwarranted to the authors even in the most complex cases, they suggest a simple way to alert surgeons of their department to the long-duration stays. As the department patient's chart represents 13 days of hospitalization, they ask surgeons make a decision upon planning the exiting of patients before adding a second chart.

Cosmetic sequelae after conservative treatment for breast cancer: classification and results of surgical correction.

After conservative treatment for breast cancer, 20% to 30% of patients have a residual deformity that sometimes requires surgical correction. Thirty-five of these patients were operated between 1990 and 1995 at the Institut Curie. The authors classify these sequelae into three types: type I, asymmetrical breasts with no deformity of the treated breast; type II, deformity of the treated breast, compatible with partial reconstruction and breast conservation; and type III, major deformity of the breast, requires mastectomy. Fourteen patients had a type I deformity; all but 1 patient were treated with mammaplasty. Seventy-one percent underwent unilateral surgery contralateral to the irradiated breast; 80% had a satisfactory cosmetic result (good or very good). Seventeen patients had a type II deformity. They were treated by various techniques (implant, mammaplasty, latissimus dorsi flap, or transverse rectus abdominis musculocutaneous flap). Only 43.8% of patients in this group had a late satisfactory cosmetic result. Four patients had a type III deformity. They were treated with mastectomy and immediate reconstruction using a musculocutaneous flap. All 4 patients had a very good cosmetic result. This classification is a valuable guide for technique selection. For type I deformities, surgery to the irradiated breast should be avoided when possible. Type II deformities raise the most difficult therapeutic problems. Because they are mainly postoperative, optimal treatment should be preventive--by performing immediate remodeling of the treated breast before radiotherapy. This pleads for integration of plastic surgical techniques at the time of the original lumpectomy, thus reducing the need for delayed reconstructive surgery.