Upper outer boundaries of the axillary dissection. Result of the SENTIBRAS protocol: Multicentric protocol using axillary reverse mapping in breast cancer patients requiring axillary dissection.

BACKGROUND: Two thirds of node-positive breast cancer patients have limited pN1 disease and could benefit from a less extensive axillary lymph node dissection (ALND). METHODS: 172 breast cancers patients requiring an ALND were prospectively enrolled in the Sentibras Protocol of Axillary Reverse Mapping (ARM). Radioisotope was injected in the ipsilateral hand the day before surgery. ALND was standard. Removed lymph nodes were classified into non radioactive nodes and radioactive nodes (ARM nodes). Among ARM nodes, nodes located in the upper outer part of the axilla, above the second intercostal brachial nerve and lateral to the lateral thoracic vein were identified as "zone D ARM nodes". The main objective was: feasibility of identification of the zone D ARM nodes. Secondary objectives were: metastatic involvement and lymphedema rate. RESULTS: 100% of patients had ARM nodes identified. The "zone D ARM nodes" were identified in 92% of cases. The rate of metastatic nodes was 60% in the all cohort, 31% in ARM nodes and 9% in zone D ARM nodes. Among those, metastatic rate was 6% in patients undergoing ALND for a positive sentinel node biopsy, 6% in case of primary ALND versus 14% after neo-adjuvant chemotherapy (p < 0.05). After 34 months of median follow up, 27% of interviewed patients had a lymphedema. CONCLUSION: The ARM technique reliably identifies the "zone D ARM nodes". These nodes can also easily be identified using knowledge of axillary anatomy. In selected patients, a selective ALND sparing the zone D ARM nodes could be performed.

Long-term oncological results after 400 skin-sparing mastectomies.

OBJECTIVE OF THE STUDY: Skin-sparing mastectomies (SSM) have gained acceptance among teams performing immediate breast reconstruction because this technique provides the best cosmetic outcome. Nevertheless, in France, concerns have been raised that limited skin excision during mastectomy could result in an increased risk of local recurrence especially in invasive breast cancer; many surgeons continue to have reservations regarding the oncologic safety of this operation. This is a retrospective, long-term follow-up study of 400 patients operated and followed by two oncoplastic surgeons. PATIENTS AND METHODS: A total of 400 patients with breast cancer underwent SSM with immediate breast reconstruction from January 1, 1992 to December 31, 2002. The American Joint Committee on Cancer pathological staging was Stage 0 (41.5%), Stage I (33.25%), Stage II (16%), Stage III (7.5%), while 1.75% were non-stageable. RESULTS: With a mean follow-up period of 88 months (range: 13-215 months), the locoregional recurrence rate was 3.5%, the rate of distant metastases was 13.5%, and 83% of patients have remained free of recurrent disease. CONCLUSION: This study provides encouraging results suggesting that skin-sparing mastectomy is a safe and reliable option for the management of selected cases of women with invasive or in situ breast cancer.

[Treatment of infected breast implant in reconstructive surgery]. / Complication infectieuse sur prothèse en chirurgie reconstructrice mammaire : quelle attitude thérapeutique adopter ?

OBJECTIVE OF THE STUDY: Immediate failure in breast surgery with implant is a serious medical complication with negative ramifications for both the patient and the health care system. The classical treatment is removal of the breast implant and delay reconstruction. Our objective is to show that this standard treatment is not the good one in many cases, and abundant irrigation with implant salvage is a sure and effective alternative. PATIENTS AND METHODS: Between January 2001 and December 2009, among the 680 patients who had a breast reconstruction, 18 were operated using the same protocol treatment by the same surgeon: implant removal, irrigation, implant replacement, antibiotic treatment. RESULTS: After a median month follow-up period of 30 months, definitive conservation of the breast implant was obtained in all of the cases. CONCLUSION: This preliminary study provides encouraging results in a selected patient population improving the possibility of a conservative treatment according to a precise and rigourous protocol.

[Prophylactic mastectomies and immediate breast reconstruction in patients at very high genetic risk: our experience with 14 cases]. / Mastectomies prophylactiques et reconstruction immédiate chez les patientes à très haut risque génétique : notre expérience à propos de 14 cas.

AIMS: Prophylactic mastectomy has been the subject of major publications by international groups. Its oncology benefit is undisputed in patients with a genetic mutation. Nevertheless, its impact on quality of life, its psychological, esthetic, sexual, functional and pain repercussions are such that it should not and must never be programmed in an emergency situation. We report our experience with 14 patients at very high genetic risk having undergone a bilateral prophylactic mastectomy with immediate breast reconstructive surgery. METHODS: From 1 March 2001 to 31 March 2006, 14 patients at very high genetic risk, seven of whom had a history of breast cancer, underwent immediate breast reconstruction with skin sparing mastectomy and preservation of the nipple-areolar complex. RESULTS: In 71.5% of the cases, we obtained a definitive conservation of the nipple-areolar complex, with esthetic results judged very satisfying. CONCLUSION: Immediate bilateral breast reconstruction by provisional or definitive implant with conservation of the skin flap and the nipple-areolar complex may constitute a positive radical issue for requesting and motivated patients at high genetic risk, managed by a multidisciplinary team.

Autologous fat transfer in reconstructive breast surgery: indications, technique and results.

AIMS: Reconstructive techniques using flaps to preserve the enveloping skin, and even the nipple areolar complex where there is no neoplastic infiltration, have led to vast improvements in the results of reconstructive breast surgery. To further improve the cosmetic outcome, we have applied the technique of autologous fat transfer or lipoinjection, which has proven very successful in cosmetic surgery, to reconstructive breast surgery, and to the treatment of certain cosmetic sequelae of conservative breast treatment. We report our findings. METHODS: From September 2001 to September 2005, 74 autologous fat transfers were undertaken in 69 patients, with 5 patients receiving injections in both breasts, to improve the cosmetic appearance through resurfacing and to repair certain sequelae of conservative breast treatment. Pre- and postoperative imaging, including MRI, were undertaken to monitor the viability of the fat grafts and detect any suspicious lesions; no suspect lesions were detected either pre- or postoperatively. RESULTS: We did not undertake overcorrection, which creates irregularities of surface or contour. Five cases of cytosteatonecrosis were reported among the 74 procedures. The mean follow-up period for the patients was 11.7 months, ranging from 1 month to 3.2 years. The panel judged improvement to be good to very good in 64 breasts (86.5%) and moderate in 10 breasts (13.5%) primarily due to lack of available adipose material for harvesting in these patients. CONCLUSION: Autologous fat transfer is now a routine procedure in our clinic due to its simplicity, safety, and reproducibility. It is systematically proposed to all of our patients as the final, perfecting procedure of breast reconstruction, irrespective of the technique used for the initial reconstructive procedure, but also to repair certain conservative treatments.

[Nipple areola complex conservation in immediate breast reconstruction: prospective study of 66 cases]. / Conservation aréolo-mamelonnaire en reconstruction mammaire immédiate: étude prospective de 66 cas.

OBJECTIVE OF THE STUDY: Our objective is to define a sub-group of patients in whom skin-sparing mastectomy with immediate reconstruction and preservation of the nipple-areola complex is technically and oncologically feasible without increasing the risk of complications and local recurrence. PATIENTS AND METHODS: Between September 1999 and December 2005, 66 patients presenting an in situ and/or invasive breast carcinoma justifying a mastectomy underwent immediate breast reconstruction preserving the skin and nipple-areolar complex. RESULTS: After a median follow-up of 37 months, definitive conservation of the nipple-areolar complex with good esthetic results was achieved in 71% of the cases. CONCLUSION: This preliminary study provides encouraging results in a selected patient population but requires a longer term follow-up in order to draw definitive conclusions on the oncological safety preserving the nipple-areolar complex.

[Function preserving surgery of limb sarcomas: history and improvements]. / Chirurgie des sarcomes des tissus mous des membres chez l'adulte : historique et avancées thérapeutiques.

In the seventies, limb-sparing surgery and radiation therapy appeared capable of successfully treating the great majority of adult patients with soft tissue sarcomas of the extremities. No survival benefit could be demonstrated in the patients selected for amputation. Microscopically positive surgical margins are related to a greater risk of local recurrence, whereas overall survival is compromised by high grade and large tumor size. Presurgery multidisciplinary discussion, management in reference center and management within cancer network independently predict conformity to the clinical practice guidelines. Reoperation should be a planned part of definitive management whenever the initial surgical procedure was done without a histologic diagnosis or was not planned to be a wide excision. Soft tissue flap reconstruction facilitates therapy for patients with locally advanced tumors so that patients with larger tumors can undergo resection, limiting complications and limb sacrifice. Vascular reconstruction is a feasible option in case of involvement of major vessels. Isolated limb perfusion (ILP) with TNF and chemotherapy is an efficient limb-sparing neoadjuvant therapy for locally advanced limb soft tissue sarcomas. Efficacy and safety of low-dose TNFalpha could greatly facilitate ILP procedures in the near future.

[The development of operating tables]. / L'épopée des tables d'opérations.

Operating tables evolved in several stages. The most dynamic period was situated between 1860 and 1920: the surgeons of numerous countries were conscious of the necessity of specific tables for surgery. Introduction of anaesthesia in 1846 and asepsis in 1870 have strongly allowed this development.

[Axillary lymphadenectomy with muscular padding, without drainage]. / Le curage de l'aisselle avec capitonnage musculaire sans drainage.

OBJECTIVE: Axillary padding without drainage appeared to be a valuable alternative technique to vacuum drainage. The technique employs local muscles or the axillary aponeurosis for padding. We report here the clinical evaluation of muscular padding without drainage. The analysis of these results prompted us to also do a literature search for other alternatives aimed at reducing morbidity due to vacuum drainage. PATIENTS AND METHODS: Muscular padding was prospectively performed by 8 different surgeons on a total of 152 patients at the Centre Rene-Huguenin (Saint-Cloud, France). Follow-up has attained 3.5 years. A comparative assessment of pain was conducted in 30 patients operated on with vacuum drainage. RESULTS: This technique is easy to learn and reproducible. It facilitates post-operative follow-up, always allowing discharge at the 2nd or 3rd post-operative day without any home nursing. The late sequels are not increased. In contrast, pain was twice more intense during the first post-operative weeks compared with vacuum drainage, and the seroma rate was also increased. DISCUSSION AND CONCLUSION: Despite good efficacy, this worsening of pain is a major obstacle to the routine use of muscular padding. A technical improvement has been published very recently where the axillary aponeurosis was used to pad the axilla. It seems to be equally efficient but less painful than muscular padding. This technique is under clinical evaluation and could appear as a valuable option to vacuum drainage. Other alternatives are discussed. Most studies lack a direct comparison with vacuum drainage and a satisfactory evaluation of quality of life is also omitted. New studies with quality of life scales are ongoing. They should allow us to choose options that take this aspect into account in the future.

Endoscopic muscular latissimus dorsi flap harvesting for immediate breast reconstruction after skin sparing mastectomy.

AIM: Immediate breast reconstruction after mastectomy using the latissimus dorsi musculo-cutaneous flap is well recognized. It allows for satisfactory aesthetic results. To minimize scanning in skin sparing mastectomy patients, we used a surgical technique consisting of an endoscopic harvesting of the latissimus dorsi pure muscular flap with a virtual cavity created by CO(2) gas distention. METHOD: Between 9 April 2001 and 30 September 2001, 8 patients underwent latissimus dorsi endoscopic harvesting for an immediate breast reconstruction after skin sparing mastectomy. RESULT: The mean operating endoscopic time was 112 minutes. No open surgical conversion was necessary. The mean lymphatic drainage was 2720 ml with removal of the drainage on post operative day 15. CONCLUSION: The endoscopic harvesting of the latissimus dorsi muscular flap, using a mixed technique of dissection guided by the lighted cleaver forceps and a closed technique by CO(2) insufflation using an endoscope is feasible, reproducible and has acceptable morbidity. This technique brings encouraging aesthetic results after skin sparing mastectomy.

[Endoscopic harvesting of the latissimus dorsi flap in breast reconstructive surgery. Feasibility study and review of the literature]. / Prélèvement endoscopique d'un lambeau musculaire pur de grand dorsal en reconstruction mammaire. Etude de faisabilité et revue de la littérature.

STUDY AIM: Breast reconstructive surgery with latissimus dorsi flap is routinely performed with a long dorsal scar ransom. To reduce the scar the authors propose an endoscopic technique to harvest the pure latissimus dorsal flap. We evaluate our first experience. PATIENTS AND METHODS: Between April 2001 and december 2001, 13 patients were operate using an endoscopic pure muscular latissimus dorsal flap for breast reconstruction surgery. RESULTS: Mean operative time is 116 min. No open conversion was necessary. One patient was transfused. The average lymphatic drainage was of 2520 ml with removal of the drainage on postoperative day 15. CONCLUSION: The endoscopic harvesting of the latissimus dorsi pure muscular flap, brings less scar than the open surgery.

[Radiotherpay and immediate breast reconstruction with myocutaneous flap in breast cancer of reserved prognosis]. / Radiothérapie et reconstruction mammaire immédiate par lambeau myocutané dans les cancers du sein de pronostic réservé.

In France, immediate breast reconstruction (IBR) for infiltrating carcinoma remains controversial. Many teams advocate the possible event of a post mastectomy radiotherapy and its negative effect on IBR. In our Institute we do not exclude infiltrating breast cancer patient from IBR. In the poor prognostic patients who wish IBR, we recommend autologous IBR to obtain the best aesthetic result with minimum revision procedures and best tolerance to adjuvant radiotherapy. From January 1993 to December 1997, we performed 687 IBR with myocutaneous flap for infiltrating carcinomas. In this group only 68 patients needed postoperative chest wall radiotherapy (45 Gy): 27 TRAM flap, 41 latissimus flap. Only one of the TRAM but 39 of latissimus flaps were associated with a prosthesis. The mean follow-up was 24 months. Fourteen patients developed metastatic disease, and ten were dead at the time of the chart revue. The autogenous TRAM flap tolerate radiation quite well and remain soft and mobile. The latissimus flap associated with a prosthesis developed capsular contracture (BAKER II or III) in 71% of cases. In all cases the cosmetic impairment was not important and the result after capsulectomy remained soft. We concluded that IBR could be offered to motivated patients in all stages of the disease regardless of the subsequent chest wall radiotherapy, and we recommend its use for possible autologous reconstruction.

[Rectus abdominis myocutaneous flaps]. / Le transplant libre myocutané de grand droit de l'abdomen.

The free transverse rectus abdominis myocutaneous (TRAM) flap is vascularized by the inferior epigastric pedicle. There are many techniques according to the indication. We describe the technique for breast reconstruction after mastectomy for cancer. The rectus muscle is taken between the umbilicus and the arcuate line. The skin paddle, was taken transversely like an abdominoplasty. The incision extends from 1 cm above the umbilicus to include the perforators around it. The mean length of the vascular epigastric pedicle is 6 cm. This study was performed from one hundred dissections.

[Breast reconstruction using free rectus abdominis myocutaneous flap]. / Reconstruction du sein pour cancer par transplant libre myocutané de grand droit de l'abdomen.

More than 50% of patients who have breast cancer do not need a mastectomy. Since 1976, reconstruction of the breast is suitable. From 1976 to 1995, we have performed 220 breast reconstructions with a pediculed latissimus dorsi and 510 reconstructions with a pediculed transverse rectus abdominis myocutaneous flap (TRAM). So, in all, 1100 immediate breast reconstruction with either a prosthesis or a pediculed flap were performed. The specialised teams aim is to use the TRAM free transplant for immediate breast reconstruction. Between 1990 to 1995 we have performed 5 free TRAM for breast reconstruction for cancer and 6 TURBOTRAM. It is important for the woman to have an abdominal adiposity, to be able to give an excellent breast. Four out of five of the free TRAM reconstructions were successful and one give partial necrosis (4 x 4 cm). All the 6 TURBOTRAM operations were uneventful. There are many advantages with this technique: the free TRAM allows a large resection of the thoracic skin and gives a natural form to the breast, without any prosthesis. The taking of the free TRAM gives only few abdominal hernia and realize an abdominoplasty. Our aim is to perform immediate breast reconstruction with free TRAM flap.

[Closure of the abdominal wall after removal of a mucocutaneous flap from the transverse rectus abdominis for breast reconstruction. Apropos of 48 cases. Review of the literature]. / Fermeture de la paroi abdominale après prélèvement musculo-cutané pour TRAM. A propos de 48 cas. Revue de la littérature.

In view of the good results of breast reconstruction with the transverse rectus abdominis myocutaneous (TRAM) flap, we used this method in 48 patients, but we observed abdominal complications, which are difficult to accept for cosmetic surgery. Hartrampf, one of pioneers of this technique, reports a very low complication, rate by closing the abdominal wall without the use of prosthetic mesh. However his results are not reproducible as numerous authors, following his technique, have reported abdominal hernias and now use prosthetic reinforcement. In the light of our experience, we analyse these complications, not only hernias, but also abdominal weakness, indicating a new operation in some cases (6/9). The quality and duration of the follow-up (52 months) accounts for the fairly high complication rate. A review of literature examines the various means of abdominal wall closure and their results. The functional injury of muscular harvesting must also be considered, especially in sports women.

[Apropos of 49 transverse rectus abdominis muscle flap (TRAM) in carcinologic and reconstructive surgery]. / A propos de quarante-neuf TRAM en chirurgie carcinologique et réparatrice.

The C.A.C. de Nice reconstructive surgery unit presents their experience of TRAM pedicled flap (41 cases) or free flap (8 cases). The technical details, complications and sequelae are analysed for the entire series of flaps with particular attention to the problems of the abdominal wall and the respective advantages of the two techniques. The applications of TRAM essentially concern breast reconstruction (41 cases) in women with large breasts and not desiring an implant or a contralateral procedure. TRAM is compared to other procedures (latissimus dorsi, implant, greater omentum) which the authors consider to be valid alternatives. The other indications are reconstructive, either for the chest wall (5 cases) or inguinoperineal (3 cases) for defects in an irradiated region.