Breast feeding after reduction mammaplasty performed during adolescence.

UNLABELLED: Reduction mammaplasty (RM) can be performed during adolescence if the functional capacity of the breast is preserved. Future breast feeding must be carefully considered in the therapeutic decision making process. PURPOSE OF THE STUDY: Breast feeding after reduction mammaplasty performed during adolescence was assessed to determine surgical factors influencing outcome and patient reception of information concerning breast feeding. METHODS: A questionnaire was sent to 109 women who had undergone reduction mammaplasty between 1981 and 1997 when they were 15-17 years old to ascertain their reasons for having surgery, their satisfaction, and their attitude towards breast feeding. RESULTS: Sixty-five questionnaires (60%) could be analyzed. Mean delay since surgery was 8.1 years. Seventeen women (26%) had delivered 25 infants (mean 1.5). Mean delay after surgery to first delivery was 7.68 years. Five women (29%) nursed their first infant for a mean 11.3 days. None of the women interrupted breast feeding for a reason related to a nipple anomaly or difficult sucking. Twelve women (71%) did not nurse their first infant, because of the prior breast surgery for six of them. Among the 48 nulliparous women, 24 (50%) stated they would nurse their future infant. Although information on breast feeding was systematically delivered, 41 women (63%) stated they had not been informed. There was no statistical relationship between breast feeding and degree of satisfaction, patient-assessed scar quality, or nipple disorders. CONCLUSION: Adolescents who undergo reduction mammaplasty can nurse their future infants with a complication rate similar to that in the general population. Special attention must be given to delivery of information on breast feeding.

[Post-inflammatory cutis laxa. A case report]. / Cutis laxa postinflammatoire. A propos d'un cas clinique.

Cutis laxa (CL) is a rare disorder in which the skin hangs in loose fields, so that affected individuals appear to be prematurely aged. The changes are more evident when effect the face with a prematurely-aged appearance. The acute form follows an inflammatory skin lesions. Its aetiology is not well known. We report a case of a head acute CL of a 17 years patient, secondary to a generalized skin eruption. The prematurely-aged appearance concern especially forehead, ear lobes and nasolabial folds. A two stages surgical treatment has associated: a forehead lifting associated to a Coleman lipofilling and an ear lobe reduction, a secondary Coleman lipofilling of the nasolabial folds. The skin biopsy confirm the diagnosis. The correction is stable and satisfactory after one year. The confrontation of our findings to those previously described confirm complexity of diagnosis and histological observations of this rare disorder.

Use of tissue expansion in revision of unhealed below-knee amputation stumps.

When local tissue is insufficient for the revision of unhealed below-knee stumps tissue expansion offers an interesting alternative for local coverage. We used this method in seven patients (five men, two women; mean age 30 years) who had had below-knee amputations, six of them after injury to a healthy limb and one for purpura fulminans. Ten tissue expanders were inflated slowly and intermittently either weekly or twice weekly depending on the patients. The mean expansion period was 92 days. Mean hospital stay for the two operations was 5.8 (range 4-9) and 7.6 (range 6-10) days, respectively. Using subjective and objective criteria, functional outcome was excellent in five patients and good in one. Expansion failed in one because of infection. Expanded skin flaps allow good cover with a minimal scar area in appropriate cases, while preserving the skin sensitivity and length of the tibial shaft.

[Juvenile breast hypertrophy: analysis of long-term results of reductive mammoplasty]. / Hypertrophie mammaire juvénile: analyse des résultats à long terme des plasties mammaires de réduction.

UNLABELLED: Reduction mammaplasty has now become routine surgery with good results in middle-aged women. However the scars it leaves, its psychological and functional (breastfeeding) impact could limited its indications in teenage girls. AIM: The purpose of our study was to report the long-term results of reduction mammaplasty in teenage girls and to assess their consequences. MATERIAL AND METHODS: We conducted a retrospective study of 65 reduction mammaplasty carried out between 1981 and 1997 in 15 to 17 years old girls. The study was based on data in their medical records and answers to a questionnaire which was sent to each patient. RESULTS: Average followup was 8.1 years. The reduction technique with superior pedicle were mainly used. Average breast tissue excised was 1050 g. Minor complications occurred in three cases. Eleven revisions had to be carried out with 1.6 years on average after primary surgery. The psychological and functional complaints observed preoperatively disappeared in more than 90% of the cases. In over 80% of the cases the patients were pleased or very pleased with the shape, the volume kept and the symmetry. Scars were well accepted in 83% of the cases. Seventeen women were given birth to 25 children. Five of whom breast-fed their babies, while six refused because of their breast surgery history. Although information about breast-feeding after such surgery is systematically given, 41 women claimed they had not received it. CONCLUSION: Reduction mammaplasty is reliable in teenage girls. Patients are generally satisfied and the remaining scar is well accepted. Breast-feeding is possible after this surgery and information on that point ought to be better developed.

[Value of pulsed color Doppler before transverse rectus abdominis musculocutaneous flap breast reconstruction. 45 cases]. / Apport du Doppler pulsé couleur avant reconstruction mammaire par lambeau myocutané de grand droit de l'abdomen. A propos de 45 cas.

The transverse rectus abdominis musculocutaneous TRAM flap is an interesting alternative for breast reconstruction after mastectomy for cancer disease in patients who refuse mammary prosthesis and when the clinical situation allows it. There is however a risk of unpredictable partial necrosis even after rigorous surgical procedure. Some authors have proposed a Doppler evaluation before reconstruction surgery to better identify the vascular network and optimize patient selection. We performed a preliminary study in 45 patients between January 1996 and December 1999. An echo-Doppler Ultramark 9 HDI (Advanced Technology Laboratories) equipped with a high frequency (10 MHz) linear probe was used to compare blood flow and vessel caliber in the superior epigastric artery and the perforating vessels (number, localization, peak flow). The results obtained in this series could be used to determine indications for TRAM flap with or without delay procedure.

Immediate breast reconstruction with deepidermalized transverse rectus abdominis musculocutaneous flap after skin-sparing mastectomy.

Use of the transverse rectus abdominis musculocutaneous (TRAM) flap for breast reconstruction is widely accepted and indications have been well-defined over the past years. More recently, the moratorium prohibiting pre-filled silicone gel implants both in esthetic surgery and in reconstruction breast surgery, has incited more and more patients to refuse prostheses, even saline filled implants. Total mastectomy with skin-sparing technique, beyond the limitations dictated by oncology factors which must be taken into account because of the risk of local recurrence, raises the question of immediate breast reconstruction since implants, when possible, may give unsatisfactory results either more or less short-term. The deepidermalized TRAM flap is an interesting alternative for selected patients, especially those with an adapted abdominal morphology, allowing stable and natural autologous breast reconstruction.

[Tuberous breast syndrome. Report on a series of 22 operated patients]. / Le syndrome du sein tubéreux. A propos d'une série de 22 patientes opérées.

The tuberous breast syndrome is a rare unilateral or bilateral breast malformation presenting at the age of mammary development. It requires surgical correction, depending on the severity of the clinical expression, because of its inaesthetic appearance. We report a series of 22 patients (35 breasts) treated and followed up in the plastic and reconstructive surgery department of Rennes over a period of nearly ten years. The average age was 18 +/- 3.2 years (range: 15-26 years old). Long-term results were assessed by the surgical team and the patients on the basis of objective and subjective criteria with an average follow-up of 36 months (12 to 116 months). In our opinion, surgical correction should be proposed after puberty with, whenever possible, section of the basal fibrous ring and glandular plasty via a periareolar incision. The use of mammary implant alone or in combination with breast tissue remodelling must be reserved for hypoplastic cases only.

[Malignant melanoma in a 7-year-old child. A report of a dramatic case]. / Mélanome malin chez une enfant de 7 ans. A propos d'un cas dramatique.

Malignant melanoma developed on the scalp at the site of a congenital nevus in a 7-year-old girl. At birth, simple observation was proposed, despite the recognized desirable but non-urgent indication for excision, in order to avoid subjecting the infant to general anesthesia. At the first sign of a change in the macroscopic appearance of the nevus, surgical resection was performed, but the short-term outcome was fatal.... This case focuses our attention on malignant progression of even small congenital nevi and emphasizes the need for early preventive and systematic resection even when the patient's age of the patient requires general anesthesia.

Preoperative color-Doppler assessment of vascularisation of the rectus abdominis: anatomic basis of breast reconstruction with a transverse rectus abdominis myocutaneous flap--a prospective study.

The unipedicled TRAM flap is an useful alternative to breast reconstruction after mastectomy in patients who refuse mammary implants. There is however the risk of unpredictable partial skin necrosis even after rigorous surgical procedures. Certain authors have proposed color flow doppler assessment before reconstructive surgery better to identify the vascular network and optimise patient selection. We performed a prospective study in 20 outpatients in order to compare preoperative assessment of the blood supply to the abdominal flap with the operative findings. An Ultramark 9 HDI (Advanced Technology Laboratories) equipped with a high frequency (10 Mhz) linear probe was used to measure blood flow and vessel caliber in the epigastric a. and perforating vessels (localisation, number; peak flow). Despite three limiting factors (anatomic, technical, morphologic) the results obtained in this series could be used to determine the indications for a TRAM flap.

[Use of tissue expansion on defective amputation stumps of the lower limbs. Apropos of 5 cases]. / Utilisation de l'expansion tissulaire dans la réfection des moignons d'amputation de membre inférieur défectueux. A propos de cinq cas.

Skin flaps are usually required to cover amputation stumps, especially below the knee. Cross-leg flaps or free flaps can be used when local tissue is insufficient, but as emphasized by Rees in 1986, tissue expansion offers another interesting possibility for local coverage. The risk of complications, especially infection, in below-knee tissue expansion is well known, requiring rigorous patient selection based on an evaluation of skin quality, vascularization, and the patient's metabolic and psychologic status. We used this method in 5 patients (3 females, 2 males; mean age 30.4 years) who had been amputated below (n = 4) and above (n = 1) the knee. In 4 cases, amputation of a healthy limb was required after trauma and in 1 case due to purpura fulminans. Seven tissue expanders were used with slow intermittent expansion applied daily. The mean expansion period was 89.4 days. Mean hospital stay for the two operations was 5.66 and 7.33 days, respectively. Assessed on the basis of subjective and objective criteria, functional outcome was excellent in 3 patients and good in one patient. Failure occurred in one case due to infection. Despite the longer treatment period, tissue expansion for skin coverage of defective amputation stumps appears to have several advantages. It is a simple, reliable and reproducible method with a minimal scar area while preserving skin sensitivity. In addition, the length of the tibial shaft can be spared and minimal modifications are needed to fit the prosthesis.

In Vitro expression of drug metabolizing enzyme activities in human adult keratinocytes under various culture conditions and their response to inducers.

In this study we analysed the expression and induction of several drug metabolizing enzymes involved in either phase I or phase II reactions, in adult human keratinocytes cultured in submerged conditions. We also evaluated the influence of confluence, subcultivation and cryopreservation on the expression of these enzymes. Besides ethoxyresorufin-O-deethylase (EROD) and glutathione S-transferase (GST) activities, which have been shown previously to be maintained in such cultures, three additional enzyme activities were measured (i.e. phenacetin deethylase, a phase I enzyme, and procainamide N-acetyltransferase and paracetamol sulfotransferase, two phase II enzymes). Post-confluent keratinocytes showed decreased activities in comparison with preconfluent cells and the different enzymes tested revealed different patterns. After confluence, some activities, such as those of procainamide N-acetyltrans-ferase, phenacetin deethylase and paracetamol sulfotransferase, showed only a slight decrease, whereas EROD and GST activities were decreased by 65 and 50%, respectively. No major differences were observed between keratinocytes in primary culture and those in second subculture. After freezing, xenobiotic metabolizing enzyme activities were only slightly reduced, if at all. Induction of EROD and GST enzymes was also analysed. Maximum EROD activity was obtained with 1 muM 3-methylcholanthrene (3-MC) and 20 muM benzanthracene (BA), in both pre-confluent and post-confluent cultures. At their optimal concentration 3-MC was a stronger inducer than BA. GST activity was slightly induced by the different compounds tested only in pre-confluent keratinocytes. In conclusion, the presence of a variety of drug metabolizing enzymes in adult human keratinocytes cultured in submerged conditions suggests that this model is suitable for investigating epidermal biotransformation of drugs and other chemicals and for determining the potential cutaneous toxicity of metabolites.

Expression of differentiation markers in human adult keratinocytes cultured in submerged conditions.

A number of studies have shown that human keratinocytes cultured in submerged conditions with non-delipidized serum do not express the major differentiation markers, i.e. 67 kDa keratin, ceramides, and lanosterol. However, they were mostly performed with neonatal or juvenile keratinocytes after a few passages, and not all the markers were analyzed in parallel. In this study, we compared the expression of several differentiation markers in preconfluent and postconfluent adult breast keratinocytes in primary and secondary cultures before and after cryopreservation. When primary cultures reached confluence, the 67 kDa keratin was synthesized, transglutaminase activity was increased, and, although overall lipid synthesis dropped, both lanosterol and free fatty acids contents were augmented. The same pattern was observed in postconfluent subcultures at Passage 2; however decreased overall lipid synthesis was more pronounced. Cryopreservation of keratinocytes just after isolation or after a few days in culture did not result in the loss of expression of these specific epidermic markers. Thus, adult breast keratinocytes in postconfluent submerged cultures represent an in vitro model that possesses various features of the normal epidermis, even after cryopreservation.

[Free latissimus dorsi flap revascularized by double venous graft on the femoral trifurcation in the treatment of lumbar radionecrosis. Apropos of 2 cases]. / Le lambeau libre de grand dorsal revascularisé par un double pontage veineux sur le trépied fémoral pour le traitement d'une radiodermite lombaire. A propos de deux cas.

Two patients were operated in 1989 and 1992 for lumbar chronic osteoradionecrosis (toxi-infection collapsus in one of the two cases). Conventional coverage procedures (skin graft, local flaps) or distally based latissimus dorsi musculo-cutaneous flap (second case) were attempted but failed. So we realised in a one stage procedure a free musculo-cutaneous flap in the case no. 1 and a free muscular flap, later skin grafted, in the case no. 2. Venous and arterial bypass were provided by 40 cm long saphenous veins harvested from the thighs, and allowed to reach the lumbar site with proximal anastomosis performed on the femoral artery. The results were considered to be excellent. That short experience shows that long venous bypass with microsurgical free transfer can be safely performed. This results in an extremely high flow shunt.

[Pectoralis major muscular flap in thoracic substance loss following mediastinitis. Apropos of 7 cases]. / Le lambeau musculaire de grand pectoral dans les pertes de substance thoracique après médiastinite. A propos de sept cas.

Mediastinitis is a rare complication but can occur after any form of cardiac surgery via midline sternotomy. Despite early diagnosis, management in intensive care and appropriate treatment, the prognosis remains severe. Progression towards a chest wall defect, exposing a sternal flap is not uncommon and requires reconstructive surgery because of the potential life-threatening risk. Among the techniques currently used, the authors emphasize the value of pectoralis major myoplasty centered on perforating vessels derived from the internal mammary artery according to the technique described by Nahai in 1982. They have performed this procedure in 7 patients with a high-risk context, always using a single muscle, and also assessed its technical simplicity, low morbidity, absence of obvious functional handicap associated with the aesthetic aspects by means of regular review with a mean follow-up of 18 months.

[Breast reconstruction in Poland syndrome. Apropos of 9 cases]. / La reconstruction mammaire dans le syndrome de Poland. A propos de neuf cas.

The authors describe their experience of breast reconstruction in Poland's syndrome and analyse 9 cases (eight females, one male) between 1981-1991. The mean age was 25 years (17-53 years). Three women were operated by the Mouly-Dufourmentel surgical procedure: translation of the homolateral latissimus dorsi muscle flap with a mammary prosthesis. The muscle flap was used alone in the male. Mammary prostheses were performed alone in four other women. Breast asymmetry was corrected by mammaplasty alone in one woman. In three cases, in order to achieve optimal symmetry, the controlateral ptosed hypertrophic breast was corrected (two cases in the same procedure, one case later). In three cases, a nipple-areolar restoration was performed at the patient's request. These results are analysed with an average follow-up of 5.4 years (2-11 years) and are compared to the literature data.

[Colpoplasty for vaginal aplasia by rectovesical dissection and thin skin graft with adjustable stent. Review of the literature apropos of 4 cases of surgically treated Mayer-Rokitansky-Küster-Hauser syndrome]. / La colpoplastie pour aplasie vaginale par clivage recto-vesical et greffe de peau mince avec conformateur gonflable. Revue de la littérature à propos de quatre cas opérés de syndrome de Mayer-Rokitansky-Küster-Hauser.

The congenital absence of the vagina has a low incidency but it is a very invalidating condition. The Mayer-Rokitansky-Küster-Hauser syndrome represents 90% of all cases of vaginal aplasia. The authors review the anatomical classification, etiopathogenesis, epidemiology, diagnosis and treatment. Between 1981 and 1991, four cases were treated by recto-vesical dissection and split thickness skin graft technique with adjustable stent. The results are good and correspond to those of the literature. Their quality and duration depend on maintaining the stent for a sufficient length of time. Frequent post-operative follow-up is necessary to prevent graft retraction and to give psychological support when it is needed.

[Forum on tissue expansion. Value of cutaneous expansion for the covering of synthetic materials used in cranioplasty. Apropos of a case]. / Forum: l'expansion tissulaire. Intérêt de l'expansion cutanée pour la couverture de matériaux synthétiques de cranioplastie. A propos d'une observation.

The authors present a case of cover of synthetic material by expanded skin. In a context of post-sepsis revision, this cover proved to be of excellent quality, superior to normal scalp. The specific characteristics of tissue expansion may possible explain, in this context, the superiority of the expanded skin. The authors intend to adopt a similar therapeutic approach is such a situation should arise in the future.

[Giant juvenile fibroadenoma in an adolescent. A case report]. / Le fibroadénome géant juvénile chez l'adolescente. A propos d'un cas.

Fibroadenomas occupy the first place, in terms of prevalence, among benign breast disorders in adolescent girls. Juvenile giant fibroadenoma is a special though rare form, which must be recognised in terms of differential diagnosis from virginal hyperplasia in its asymmetrical early form and phylloid tumours, the prognosis of which is different. The authors describe the clinical and pathological features necessary for diagnosis and report the results of breast reconstruction after excision via a lateral radial approach in a 14-year-old adolescent girl.

[Treatment of incisional hernia of the abdominal wall by the skin lacing technique. Apropos of 30 cases]. / Traitement des éventrations de la paroi abdominale par la technique du laçage à la peau. A propos de trente observations.

The treatment of large incisional hernias is often difficult, as reflected by the many surgical techniques proposed and the high recurrence rate. Since 1983, the authors have used a skin lacing procedure in these large hernias which frequently tend to recur. This report was based on the study of 30 consecutively patients operated by this method between 1983 and 1989. The objective results evaluated clinically in terms of the quality of the abdominal wall after more than two years of follow-up appear to argue in favour of this little known technique which combines simplicity, rapidity and reliability. Based on their experience, the authors believe that this method has a place in the therapeutic arsenal for abdominal wall repair as, in some cases, it can resolve the difficult problem of treatment of large, recurrent incisional hernias regardless of the patient's age.

[Therapeutic attitude in extensive cutaneous lesions in Recklinghausen's disease]. / Attitude thérapeutique dans les lésions cutanées étendues de la maladie de Recklinghausen.

Based on our experience with von Recklinghausen's disease, we present two cases characterized by highly developed skin tumors. One of these cases is unique in the literature. After describing these two cases, we review the different sites of the disease and discuss the limitations of surgery. Particular attention is paid to surgical palliation for patients with end-stage tumors.