Intraoperative augmented reality with heads-up displays in maxillofacial surgery: a systematic review of the literature and a classification of relevant technologies.

Although the term augmented reality appears increasingly in published studies, the real-time, image-guided (so-called 'hands-free' and 'heads-up') surgery techniques are often confused with other virtual imaging procedures. A systematic review of the literature was conducted to classify augmented reality applications in the fields of maxillofacial surgery. Publications containing the terms 'augmented reality', 'hybrid reality', and 'surgery' were sought through a search of three medical databases, covering the years 1995-2018. Thirteen publications containing enough usable data to perform a comparative analysis of methods used and results obtained were identified. Five out of 13 described a method based on a hands-free and heads-up augmented reality approach using smart glasses or a headset combined with tracking. Most of the publications reported a minimum error of less than 1mm between the virtual model and the patient. Augmented reality during surgery may be classified into four categories: heads-up guided surgery (type I) with tracking (Ia) or without tracking (Ib); guided surgery using a semi-transparent screen (type II); guided surgery based on the digital projection of images onto the patient (type III); and guided surgery based on the transfer of digital data to a monitor display (type IV).

[Breast reconstruction by prosthesis]. / La reconstruction mammaire par prothèse.

Breast reconstruction by prosthesis remains the most used in the world and even tends to increase again at the expense of musculo-cutaneous flaps since the systematic use, in recent years, of adipocytes grafts (lipofilling) before and/or after in place of the implant. This simpler technique is often preferred by patients who want to avoid scars and pain away from the chest area. The use of different implant forms, fat injection, abdominal advancement flaps, biological or synthetic matrices can significantly improve the results of these reconstructions in secondary or immediate. All these techniques are detailed in the following article to show the different devices that allow to achieve this intervention with maximum security.

[Identification of perforating vessels by augmented reality: Application for the deep inferior epigastric perforator flap]. / Repérage des vaisseaux perforants par réalité augmentée : application au lambeau perforant d'artère épigastrique inférieure profonde.

The augmented reality on smart glasses allows the surgeon to visualize three-dimensional virtual objects during surgery, superimposed in real time to the anatomy of the patient. This makes it possible to preserve the vision of the surgical field and to dispose of added computerized information without the need to use a physical surgical guide or a deported screen. TECHNIQUE: The three-dimensional objects that we used and visualized in augmented reality came from the reconstructions made from the CT-scans of the patients. These objects have been transferred through a dedicated application on stereoscopic smart glasses. The positioning and the stabilization of the virtual layers on the anatomy of the patients were obtained thanks to the recognition, by the glasses, of a tracker placed on the skin. We used this technology, in addition to the usual locating methods for preoperative planning and the selection of perforating vessels for 12 patients operated on a breast reconstruction, by perforating flap of deep lower epigastric artery. The "hands-free" smart glasses with two stereoscopic screens make it possible to provide the reconstructive surgeon with binocular visualization in the operative field of the vessels identified with the CT-scan.

Extensive pure ductal carcinoma in situ of the breast: identification of predictors of associated infiltrating carcinoma and lymph node metastasis before immediate reconstructive surgery.

AIM: To identify predictors for infiltrating carcinoma and lymph node involvement, before immediate breast reconstructive surgery, in patients with an initial diagnosis of extensive pure ductal carcinoma in situ of the breast (DCIS). PATIENTS AND METHODS: Between January 2000 and December 2009, 241 patients with pure extensive DCIS in preoperative biopsy had underwent mastectomy. Axillary staging (sentinel node and/or axillary dissection) was performed in 92% (n = 221) of patients. Patients with micro-invasive lesions at initial diagnosis, recurrence or contralateral breast cancer were excluded. RESULTS: Respectively 14% and 21% of patients had a final diagnosis of micro-invasive carcinoma (MIC) and invasive ductal carcinoma (IDC). Univariate analysis showed that the following variables at diagnosis were significantly correlated with the presence of either MIC or IDC in the mastectomy specimen: palpable tumor (p = 0.002), high grade DCIS (p = 0.002) and detection of an opacity by mammography (p = 0.019). Axillary lymph node (ALN) involvement was reported in 9% of patients. Univariate analysis suggested that a body mass index higher than 25 (p = 0.007), a palpable tumor (p = 0.012) and the detection of an opacity by mammography (p = 0.044) were associated with an increased rate of ALN involvement. CONCLUSION: Skin-sparing mastectomy and immediate breast reconstruction (IBRS) has become increasingly popular, especially for patients with extended DCIS of the breast. This study confirmed that extended DCIS is associated with a substantial risk of finding MIC or IDC on the surgical specimen but also ALN involvement. Adjuvant systemic treatment and/or radiotherapy could be indicated for some of these patients after the surgery. Patients should be informed of the rate of 1) complications associated to IBRS that will potentially delay the introduction of systemic or local therapy 2) complications associated to radiotherapy after IBRS.

Monoamines tissue content analysis reveals restricted and site-specific correlations in brain regions involved in cognition.

The dopamine (DA), noradrenalin (NA) and serotonin (5-HT) monoaminergic systems are deeply involved in cognitive processes via their influence on cortical and subcortical regions. The widespread distribution of these monoaminergic networks is one of the main difficulties in analyzing their functions and interactions. To address this complexity, we assessed whether inter-individual differences in monoamine tissue contents of various brain areas could provide information about their functional relationships. We used a sensitive biochemical approach to map endogenous monoamine tissue content in 20 rat brain areas involved in cognition, including 10 cortical areas and examined correlations within and between the monoaminergic systems. Whereas DA content and its respective metabolite largely varied across brain regions, the NA and 5-HT contents were relatively homogenous. As expected, the tissue content varied among individuals. Our analyses revealed a few specific relationships (10%) between the tissue content of each monoamine in paired brain regions and even between monoamines in paired brain regions. The tissue contents of NA, 5-HT and DA were inter-correlated with a high incidence when looking at a specific brain region. Most correlations found between cortical areas were positive while some cortico-subcortical relationships regarding the DA, NA and 5-HT tissue contents were negative, in particular for DA content. In conclusion, this work provides a useful database of the monoamine tissue content in numerous brain regions. It suggests that the regulation of these neuromodulatory systems is achieved mainly at the terminals, and that each of these systems contributes to the regulation of the other two.

Prediction of axillary lymph node status in male breast carcinoma.

BACKGROUND: To evaluate whether predictive factors of axillary lymph node metastasis in female breast cancer (BC) are similar in male BC. PATIENTS AND METHODS: From January 1994 to May 2011, we recorded 80 non-metastatic male BC treated at Institut Curie (IC). We analysed the calibration and discrimination performance of two nomograms [IC, Memorian Sloan-Kettering Cancer Center (MSKCC)] originally designed to predict axillary lymph node metastases in female BC. RESULTS: About 55% and 24% of the tumours were pT1 and pT4, respectively. Nearly 46% demonstrated axillary lymph node metastasis. About 99% were oestrogen receptor positive and 94% HER2 negative. Lymph node status was the only significant prognostic factor of overall survival (P = 0.012). The area under curve (AUC) of IC and MSKCC nomograms were 0.66 (95% CI 0.54-0.79) and 0.64 (95% CI 0.52-0.76), respectively. The calibration of these two models was inadequate. CONCLUSIONS: Multi-variate models designed to predict axillary lymph node metastases for female BC were not effective in our male BC series. Our results may be explained by (i) small sample size (ii) different biological determinants influencing axillary metastasis in male BC compared with female BC.

Reconstrucción mamaria por turbo tram: estudio prospectivo, comparativo / Tram breast reconstruction by turbo

Hoy una reconstrucción mamaria (RM) por cualquierade los métodos deben ser consideradas en casi todoslos casos. El colgajo autólogo que corresponde al excesograso-cutáneo abdominal inferior ligado al músculo rectoanterior, ocupa un lugar importante en reconstrucción delseno, visto sus ventajas cosméticas y de estabilidad en eltiempo. . En los casos deriesgo de necrosis se ha optado en el servicio por la opciónde una micro-anastomosis de tal manera a mejorar laperfusión y drenaje del colgajo.Este estudio prospectivo realizado en el InstitutoCurie esta basado en 35 casos de reconstrucciones mamariaspor CMC (colgajo músculo-cutáneo) del recto anterior del abdomen según dos modalidades; monopediculadossimples (14 pacientes), monopediculado turbo(21 pacientes). Se ha evaluado la fuerza de la pared abdominalen pre y posoperatorio, considerando dos gruposmusculares. (Recto anterior y oblicuos). Así mismolas complicaciones y resultados cosméticos a nivel de lapared abdominal y del seno reconstruido. Hemos constatado25% de eventraciones y seudo-eventraciones, todoscasos de utilización de mallas reabsorvibles para el cierreabdominal. La evaluación pre operatoria de la fuerza dela porción supra umbilical (PSU) de recto anterior del abdomenmuestra que el 80% de los pacientes obtuvieronpuntuaciones satisfactorias según la escala de Lacote. Entanto que para la porción infla umbilical (PIU), más del90% de los pacientes obtuvieron igual puntaje. Las cifrasdel postoperatorio se alejan, revelando estabilidad de lospuntajes en apenas 30% de casos para la PSU, contra 80%para la PIU. Los análisis evidencian una deterioración superioral 50% para la PSU del recto anterior, alcanzandoapenas el 30 para la PIU. Confirmamos en este estudio que la disminución dela fuerza muscular del recto anterior es más marcada parala PSU que para la PIU, independientemente del tipo detécnica de TRAM utilizada.

Management of exposed, infected implant-based breast reconstruction and strategies for salvage.

INTRODUCTION: Complications of implant-based breast reconstruction are rare but mastectomy flap necrosis and peri-implant infection are the most frequent and remain an important cause of early implant failure. This study aimed to compare the results of three different management strategies employed to deal with these complications at our institution. PATIENTS AND METHODS: A consecutive series of 71 infected/exposed prostheses in 68 patients over a 20-year period were analysed. Management strategies included explantation and delayed reconstruction, implant salvage and explantation and immediate autologous reconstruction. RESULTS: Only 19 of 45 (42%), managed with implant removal, went on to delayed reconstruction. Methods of delayed reconstruction were distributed equally between implant-only, implant and autologous tissue and autologous-only reconstructions. The implant was successfully salvaged in nine cases, but reducing the implant size or introducing new tissue as a flap increased the success from 45% to 53%. Three patients with infected implant-only breast reconstruction underwent explantation and immediate conversion to autologous-only reconstructions. CONCLUSIONS: All the three interventions reviewed here have their place in the management of infected implant-based breast reconstructions. It is noteworthy that following implant removal, the likelihood of the patient proceeding to delayed reconstruction of any kind is similar to the likelihood of successful salvage (42% vs. 45%). This study population had high numbers of exposed implants in irradiated fields. Reducing implant size or introducing new tissue in the form of a flap increases the chances of successful implant salvage. In the presence of mild infection, removal of exposed/infected implants and immediate conversion to an autologous-only reconstruction can prove to be successful.

Oncoplastic breast surgery: a review and systematic approach.

Oncoplastic breast surgery (OBS) is relatively new, but has made rapid progress from its tentative steps of infancy in the 1990s. The recent Milanese Consensus Conference on Breast Conservation concluded that, firstly, oncoplastic techniques are warranted to allow wide excision and clear margins without compromising cosmesis. Secondly, such surgery is ideally performed at the same time as oncological excision. Whilst technically more challenging than standard breast conserving therapy (BCT), OBS is well proven, if not yet widely practised, both oncologically and aesthetically and a review of the available techniques is perhaps timely. The roots of breast conserving therapy can be traced to the 1930s, actually due to advances made in radiotherapy, and the last 20 years have seen it become firmly established. This review aims to summarise the key historical developments and latest innovations in OBS. Not only are our patients, who expect not only safe cancer treatment but a satisfactory aesthetic outcome, increasingly informed and demanding, but longer follow up has stimulated surgeons to improve outcomes. In many cases, particularly with ptosis and macromastia, the cancer can be treated, usually with wider excision margins, simultaneously improving the aesthetic appearance. Present at the birth of OBS, the Institut Curie has continued to introduce innovative techniques over the last two decades and a systematic approach, comprising nine basic techniques, has evolved to allow high quality treatment of any and all breast cancers suitable for OBS.

Lateral mammaplasty reconstruction after surgery for breast cancer.

BACKGROUND: Up to 60 per cent of cancers develop laterally in the breast and breast-conserving surgery frequently produces superolateral nipple-areolar complex (NAC) distortion aggravated by postoperative irradiation. Correction is technically demanding and the outcomes are variable. Lateral mammaplasty may allow wider excision margins and prevent such deformities. METHODS: This was a review of 86 consecutive patients who had lateral mammaplasty: combined wide tumour excision with NAC repositioning on a reliable dermoglandular pedicle. Simultaneous axillary surgery was performed via a separate or combined incision. Aesthetic outcomes were assessed. RESULTS: The median age of the women was 54 (range 29-75) years; 55 (64 per cent) had palpable tumours and 73 (85 per cent) underwent simultaneous axillary surgery. Median radiological and histological tumour sizes were 29.8 and 33.6 mm, respectively, and median weight of excised tumour was 150 g. Two patients required haematoma evacuation. Eleven women required revisional surgery for involved or close margins. Aesthetic outcomes were excellent or good in 93 per cent. CONCLUSION: Lateral mammaplasty produced clear margins in 87 per cent of women. It is an option when a deformity is anticipated after breast-conserving surgery, and is particularly valuable when neoadjuvant chemotherapy has downgraded a large tumour.

[Secondary breast reconstruction using exclusive lipofilling]. / Reconstruction mammaire secondaire par lipomodelage exclusif.

Lipofilling is usually performed in breast surgery for treatment of aesthetics sequelae after breast conserving surgery or correction after breast reconstruction by prothesis or musculocutaneous flaps. We present a case of a patient where exclusive lipofilling breast reconstruction has been successfully performed. Aesthetic result is assessed by the patient and the surgeon as very satisfactory after one year of follow-up. This technology not much used in this present indication have important advantages in terms of tolerance or morbidness but the long-term results depend on not controlled factors such as volumetric cast iron or fatty resorption. Further studies are necessary to define the patients will be able to benefit from this technology and to assess the modalities of follow-up but also to measure evenly practicability, stability of reconstruction and its evolution in time. However, aesthetic result and contentment of the patient allow us to envisage the broadcasting of this technology of mammary reconstruction for selected patients.

[Nipple and areola reconstruction by tattooing, "F" and "Z" flaps]. / La reconstruction de la plaque aréolo-mamelonnaire par tatouage, lambeaux << F >> et << Z >>

Nipple and areola reconstruction is very important in the evaluation of the quality of breast reconstruction. It can be done during the primary or secondary breast reconstruction or later. We have performed the techniques of nipple reconstruction routinely since 1992. Under local anesthesia during a second operative time or general anesthesia during breast reconstruction, the local "F" and "Z" skin flaps and tattooing grant a quality result in the wound and the long-term projection. They are easily reproduced, rapid and as there is no graft the choice of the incisions grants a good tolerance. Complications are rare and it is always possible to use other techniques in case of poor result. We also present the main techniques of nipple and areola reconstruction with their advantages and limits.

[Partial reconstruction after conservative treatment for breast cancer: classification of sequelae and treatment options]. / Séquelles esthétiques du traitement conservateur des cancers du sein: une classification pour les reconstructions après tumorectomie.

Most patients presenting with breast cancer are treated by breast conserving treatment (BCT). Some of these patients present with poor cosmetic results and ask for partial breast reconstruction. These reconstructions following BCT are presenting more frequently to plastic surgeons as a difficult management problem. We have defined and published a classification of the different cosmetic sequelae (CS) after BCT into three types. This classification helps to analyse these complex deformities aggravated by radiotherapy. Furthermore, our classification helps to choose between the different surgical techniques and propose the optimal option for their surgical correction. Our initial publications reported 35 and 85 patients: we have currently operated more than 150 cases of CS after BCT. Type-1 CS are defined by an asymmetry between the two breasts, with no distortion or deformity of the radiated breast. Type-2 CS are those with an obvious breast deformity, that can be corrected with a partial reconstruction of the breast. Type-3 CS are those with such a deformity that only a mastectomy with total reconstruction of the breast can be performed. Most of the patients present with type-2 CS, but are reluctant to undergo what they feel is a major reconstructive procedure: in a initial prospective series of 85 patients operated for CS after BCT, 48 (56.5%) had type-1 CS, 33 patients (38.8%) type-2 CS and four patients (4.7%) type-3 CS. Type-1 patients should be managed essentially by contralateral symmetrizing procedures. One should limit any surgery on the radiated breast, as a mammoplasty or an augmentation is at high risk of complications. Type-2 is the most difficult to manage and requires all the surgical armamentarium of breast reconstructive surgery. The insetting of a myocutaneous flap is often necessary and autologous fat grafting is a promising tool in selected cases. Type-3 CS requires mastectomy and immediate reconstruction with a myocutaneous flap. The major development though in the past 10 years has been the development of oncoplastic techniques at the time of the original tumour removal, in order to avoid most of type 2 and type 3 deformities. This paper reaffirms the validity of the Cosmetic Sequelae classification as a simple, practical guide for breast reconstructive surgeons. It discusses the various choices of reconstructive procedures available, the importance of "preventing" these CS and defining the role of the plastic surgeon in the management of these patients.

[Breast cancer surgery: use of mammaplasty. Results. Series of 298 cases]. / Résultats carcinologiques et esthétiques du traitement du cancer du sein par plastie mammaire. 298 cas.

Breast cancer surgery has long consisted in the sole use of mastectomy. Then, it was proved that, in terms of global survival, conservative treatments associated with radiotherapies could give the same results. But breast deformations due to classic conservative treatments led some authors to use plastic surgery procedures: breast plastic surgery. Some breast plastic surgery procedures are well-known, others have been adapted to breast cancer treatment and more particularly in case of tumor of superior and internal quadrants. After the retrospective analysis of a series of 298 cases from the Institute Curie, the aim of this survey is to find whether there is a difference between: breast plastic surgery and usual treatments like mastectomy and classic conservative treatments. For most cases, the tumors were invasive ductal carcinoma and T2N0M0 carcinoma. This survey showed, among these cases, 94.56% of global survival, 86.81% of survival without metastasis and a five-year 93.47% without local recurrence, which is comparable to the results for mastectomies and classic conservative treatments. In selected cases, the use of mammaplasty could be interesting for breast cancer surgery treatment.