Avoiding post mastectomy lateral "Dog Ears" by an L incision and lipoaspiration: The Paris Breast Center technique.

BACKGROUND: Lateral dog ear after mastectomy in overweight or large breasted patients is a source for patient discomfort and is aesthetically unpleasing. Although many different techniques have been proposed, none of them have emerged as standard. In 2012, the authors published their mastectomy technique based on an inverted L-scar incision and closure with a lateral skin flap advanced supero-medially onto the chest wall. Authors sought to report their experience with this technique in patients with wide or large breasts operated with mastectomy without immediate breast reconstruction. As a refinement to their initial technique, they added lipoaspiration to the lateral chest wall. METHODS: A retrospective study identified 43 patients operated on using the L incision and lipoaspiration from January 2015 to January 2021. Patient and tumor characteristics, operative details, post-operative results, and complications were recorded. Patients were followed-up and assessed for arm motion restriction, lymphedema, and recurrence. RESULTS: The mean age was 68 years; the mean BMI was 29 kg/m 2. The mean follow-up was 32 months. The mean weight of the mastectomy specimen was 1009 g and the mean aspirated volume in the lateral chest wall was 450 mL. One patient had a hematoma, four patients had seroma, and one patient developed a minor wound dehiscence. No skin necrosis or arm movement restriction was observed. Two patients developed mild lymphedema. Three patients underwent delayed breast reconstruction. CONCLUSION: The proposed technique is a safe and effective method to avoid lateral dog deformity after mastectomy, achieving both functional and cosmetic outcomes.

Fat Grafting before Delayed Prophylactic Mastectomy and Immediate Implant Reconstruction for Patients at High Risk of Complications.

SUMMARY: The majority of patients undergoing bilateral prophylactic mastectomy request immediate implant-based breast reconstruction. Some patients, especially those with prior radiotherapy, are at increased risk of early cutaneous complications and implant loss. The authors developed the technique of primary fat grafting before delayed prophylactic mastectomy to minimize early complications for selective high-risk patients. They have completed 21 cases in 14 patients, 10 of whom had previous lumpectomy and radiation treatment for breast cancer. A single session of fat grafting, with a median injection volume of 250 ml (interquartile range, 200 to 300 ml), was performed a median period of 19 weeks (interquartile range, 16 to 28 weeks) before prophylactic mastectomy. All cases were direct-to-implant reconstruction using textured silicone implants. The median implant volume was 410 ml (interquartile range, 318 to 450 ml). A minor early complication developed in 14 percent of cases (three of 21), with no early implant loss. At a median follow-up of 9 months (interquartile range, 5 to 27 months), the authors found no cases of implant loss and an excellent or good aesthetic outcome (score of 5 or 4) in 16 of 21 cases (76 percent). Fat grafting before prophylactic mastectomy is a novel strategy to minimize early complications and avoid implant loss in patients at high risk of postoperative complications. . CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Salvaging the infected breast implant: results of a retrospective series of 80 consecutive cases.

BACKGROUND: Breast implants are widely used in reconstruction after breast cancer. Infection after implant reconstruction is a major complication, with rates ranging from 5 to 30%. This rate is less for pure cosmetic augmentation. Historically, infection of an implant mandated implant removal for sepsis control. An alternative is to attempt to salvage the infected implant. This path can be a long one, requiring surgery for washouts and prolonged antibiotic therapy. This article documents our experience of infected implant salvage over the last 13 years. METHODS: We conducted a retrospective analysis of all patients who developed a breast implant infection between January 2005 and January 2018. All patients had both clinical signs of infection and a positive bacteriological sample. Patients were divided into two groups: upfront medical therapy (including those requiring secondary surgical salvage) and primary surgery. The salvage procedure was defined as successful when the implant was still in place three months after the initial reconstruction. RESULTS: Eighty patients were included: 77 in the medical group and 3 in the surgical group. Overall, implant salvage was achieved in 88.8% of women (n=71). Of these, 73.8% (n=59) underwent medical treatment alone and 15% (n=12) underwent medical treatment followed by surgical management. The main causative organism was staphylococcus in 81.2%. When the infection was caused by a coagulase-negative staphylococcus, the rate of success was 98% (p<0.003). CONCLUSIONS: This case series reports that salvage of an infected breast implant was achievable in up to 90% of women presenting with a documented infection, the majority requiring antibiotic management only. Early intervention is central to success.

Breast-conserving therapy can be offered to women with prior breast augmentation.

INTRODUCTION: Breast cancer in women with cosmetic breast implants is increasingly common. Over the past decade, there has been a push for mastectomy and reconstruction in these patients, based on a fear of poor aesthetic results from small breast volume, and radiation-induced capsular contracture. At the Paris Breast Centre, augmented women routinely undergo lumpectomy with whole-breast irradiation (BCT). MATERIALS AND METHODS: A consecutive cohort of 50 augmented women, who had attempted BCT for early breast cancer at our institution between 2003 and 2018, were retrospectively identified. Post-treatment complications, oncologic outcomes, capsular contracture rates, long-term cosmetic outcomes, and patient-reported outcomes were evaluated. RESULTS: The median follow-up was 51 months. Margins were involved in 7 women (14%); 4 of whom underwent successful re-excision, and 3 had a mastectomy, for an early mastectomy rate of 6%. There were no early complications, nor cases of early implant loss. Long-term aesthetic results were evaluated using our 5-point scale: An excellent (5), or good (4) result was obtained in 68%. Significant capsular contracture (Baker grade 3 or 4) developed in 34%, of which, 5 women underwent capsulotomy and fat grafting; 4 of 5 downstaging their Baker grade. The estimated 5-year local recurrence rate was 2.3%. Ninety-five percent of participants would recommend BCT to augmented women. CONCLUSION: BCT is feasible and safe in augmented women with good long-term aesthetic results, and should be considered to avoid unnecessary mastectomy.

Relationship between Patient Age and Disease Features in a Prospective Cohort of 1560 Women Affected by Endometriosis.

OBJECTIVE: To assess the relationship between age, location of the disease, and surgical procedures performed in patients undergoing surgical management of endometriosis. DESIGN: Retrospective study using data prospectively recorded in the North-West Inter Regional Female Cohort for Patients with Endometriosis database. SETTING: University tertiary referral center. PATIENTS: Women who underwent surgical management of symptomatic endometriosis between April 2009 and April 2014. INTERVENTIONS: Patients were allocated to 6 groups according to their age at the time of surgery: ≤20, 21 to 25, 26 to 30, 31 to 35, 36 to 40 and >40 years. Patient characteristics, prior history, location of endometriotic lesions, stage of disease, intraoperative findings, and surgical procedures were retrieved from a prospectively recorded database. MEASUREMENTS AND MAIN RESULTS: Patient characteristics, symptoms, location of endometriosis, and type of surgery performed were compared between groups. In total, 1560 procedures were performed. Of these, more than one-half were carried out in women between the age of 26 to 35 years and the majority were performed in women aged between 26 and 30 years. Only 2% of procedures were performed in women under the age of 20 years. The mean stage of the disease at the time of surgical diagnosis was stage II for women younger than 20 years, stage III for those in the age group of 21 to 25 years, and stage IV for those older than 26 years. The rate of diagnosis of deep colorectal nodules increased progressively from 20 to 26 years and remained stable thereafter. CONCLUSION: Our data confirm that endometriosis is a disease that probably progresses from adolescence until the adult period when symptoms (pain or infertility) become debilitating and require surgery. Our data suggest that policies relating to the prevention and early diagnosis of endometriosis should focus on women younger than 25 years.

Multiple Nodule Removal by Disc Excision and Segmental Resection in Multifocal Colorectal Endometriosis.

STUDY OBJECTIVE: To report postoperative outcomes after dual digestive resection for deep endometriosis infiltrating the rectum and the colon. DESIGN: A retrospective study using data prospectively recorded in the CIRENDO database (Canadian Task Force classification II-2). SETTING: A university tertiary referral center. PATIENTS: Twenty-one patients managed for multiple colorectal deep endometriosis infiltrating nodules. INTERVENTIONS: Concomitant disc excision and segmental resection of both the rectum and sigmoid colon. MEASUREMENTS AND MAIN RESULTS: The assessment of postoperative outcomes was performed. Rectal nodules were managed by disc excision and segmental resection in 20 patients and 1 patient, respectively. Sigmoid colon nodules were removed by short segmental resection and disc excision in 15 and 6 patients, respectively. The rectal nodule diameter was between 1 and 3 cm and over 3 cm in 33% and 67% of patients, respectively. Associated vaginal infiltration requiring vaginal excision was recorded in 76.2% of patients. The mean diameter of the rectal disc removed averaged 4.6 cm, and the mean height of the rectal suture was 5.8 cm. The length of the sigmoid colon specimen and the height of the anastomosis were 7.3 cm and 18.5 cm, respectively. The mean operative time was 290 minutes, and the mean postoperative follow-up averaged 30 months. Clavien-Dindo 3 complications occurred in 28% of patients, including 4 with rectal fistulae (19%). The pregnancy rate was 67% among patients with pregnancy intention. CONCLUSION: Our data suggest that combining disc excision and segmental resection to remove multiple deep endometriosis nodules infiltrating the rectum and the sigmoid colon can preserve the healthy bowel located between 2 consecutive nodules. However, the rate of postoperative complications is high, particularly in patients with large low rectal nodules.

Rectal Shaving Using Plasma Energy in Deep Infiltrating Endometriosis of the Rectum: Four Years of Experience.

STUDY OBJECTIVE: To evaluate postoperative complications, digestive function and fertility outcomes in patients managed by rectal shaving using plasma energy in deep infiltrating endometriosis of the rectum. DESIGN: A single-center retrospective cohort study using data recorded prospectively. DESIGN CLASSIFICATION: Canadian Task Force classification II-2. SETTINGS: Department of Gynecology and Obstetrics of Rouen University Hospital (France). PATIENTS: One hundred and ten patients treated between December 2012 and December 2016. INTERVENTIONS: Laparoscopic rectal shaving using plasma energy. MEASUREMENTS AND MAIN RESULTS: Clinical history, baseline symptoms, preoperative assessment, intraoperative findings, and postoperative outcomes were recorded prospectively. Follow-up evaluations were performed at 1 year and 3 years. Mean age of patients was 37 ± 6.4 years. Most patients had rectal nodules infiltrating either the mid or upper rectum and measuring <3 cm long. No intraoperative complications were recorded. One patient with multiple previous surgical procedures presented with a postoperative rectovaginal fistula (0.9%), and 1 patient presented with a postoperative rectouterine fistula treated exclusively with antibiotics (0.9%). Two patients (1.8%) had bladder atony necessitating ≥3 weeks of daily self-catheterization. Four patients (3.6%) had Clavien-Dindo grade I complications, 12 (10.9%) had grade II complications, 1 (0.9%) had a grade IIIa complication, 5 (4.5%) had grade IIIb complications, and 1 (0.9%) had a grade 4a complication. The vast majority of patients (n = 103 patients; 93.6%) were free of serious complications. Significant improvements in constipation and gastrointestinal quality of life were recorded at 1 year and 3 years postoperatively. Thirty-two patients attempted pregnancy after surgery (29.1%), and 17 of them conceived (53.1%). CONCLUSIONS: Rectal shaving using plasma energy allows for a low rate of postoperative complications with good digestive function and fertility outcomes and appears to be suitable in selected women with symptomatic rectal endometriosis.

Does preoperative antimüllerian hormone level influence postoperative pregnancy rate in women undergoing surgery for severe endometriosis?

OBJECTIVE: To compare postoperative pregnancy rates as they relate to presurgery antimüllerian hormone (AMH) level in patients with stage 3 and 4 endometriosis. DESIGN: Retrospective comparative study using data prospectively recorded in the North-West Inter-Regional Female Cohort for Patients with Endometriosis (CIRENDO) database. SETTING: University tertiary referral center. PATIENT(S): One hundred eighty patients with stage 3 and 4 endometriosis and pregnancy intention, managed from June 2010 to March 2015, were divided into two groups according to their preoperative AMH levels: group A (AMH ≥2 ng/mL) and group B (AMH <2 ng/mL). INTERVENTION(S): Surgical procedure involved ovarian endometrioma ablation by plasma energy along with resection of various localizations of the disease. Postoperative conception was either spontaneous or used assisted reproductive technology, depending on patient characteristics. MAIN OUTCOME MEASURE(S): Patient characteristics, preoperative symptoms, infertility history, intraoperative findings, and probability of pregnancy were recorded and compared between the two groups. RESULT(S): Among 180 women enrolled in the study, 134 (74.4%) were assigned to group A and 46 (25.6%) to group B. The women's ages were, respectively, 30 ± 3.8 and 32 ± 4.6 years. Pregnancy was achieved by 134 (74.4%) patients, and conception was spontaneous in 74 of them (55.2%). Pregnancy rates in groups A and B were, respectively, 74.6% (100 women) and 73.9% (34 women), while spontaneous conception represented 54% (54 women) and 58.8% (20 women). The probability of pregnancy at 12, 24, and 36 months after surgery in groups A and B was comparable, respectively, 65% (95% confidence interval [CI], 55%-75%), 77% (95% CI, 86%-68%), and 83% (95% CI, 90%-75%) versus 50% (95% CI, 69%-34%), 77% (95% CI, 90%-61%), and 83% (95% CI, 94%-68%). Supplementary analysis in women with normal (≥2 ng/mL), low (1-1.99 ng/mL), and very low (<1 ng/mL) AMH level showed an inverse relationship between AMH level, age, and antecedents of miscarriage; however, postoperative pregnancy rates were comparable among the three groups at 12 and 24 months, respectively, 59.5% (95% CI, 49.3%-70%) and 77.4% (95% CI, 68%-85.4%); 57.1% (95% CI, 34%-83%) and 78.6% (95% CI, 55.2%-94.8%); and 46.7% (95% CI, 25.6%-73.7%) and 73.3% (95% CI, 50.4%-91.7%). CONCLUSION(S): The probability of postoperative pregnancy was comparable between women with low and normal AMH level who were managed for stage 3 and 4 endometriosis and who were a mean age of 30 years. However, the small sample size might have been unable to detect differences in pregnancy and live-birth rates between the two groups. As the majority of pregnancies were spontaneous, our results suggest that surgical management may be offered to young patients with severe endometriosis and reduced ovarian reserve with good fertility outcomes.

Continuous Amenorrhea May Be Insufficient to Stop the Progression of Colorectal Endometriosis.

We present the case of a patient in whom consecutive imaging assessment and surgery demonstrated the obvious progression of colorectal endometriosis under continuous medical therapy. A 26-year-old nullipara presented with secondary dysmenorrhea, deep dyspareunia, diarrhea, and constipation during menstruation. Magnetic resonance imaging (MRI) assessment revealed 2 right ovarian endometriomas, but no deep endometriosis lesion. Intraoperatively, we found a 2-cm length of thickened and congestive area of sigmoid colon, along with small superficial lesions arising in the small bowel and appendix. We performed ablation of ovarian endometriomas and appendectomy, and decided to not resect the bowel. Postoperative computed tomography-based virtual colonoscopy (CTC) revealed a slight abnormality of the sigmoid colon. Endorectal ultrasound identified a normal rectum and sigmoid colon. Despite long-term continuous medical treatment, the patient presented 4 years later with impaired digestion consisting in constipation alternating with diarrhea, bloating, dyschesia, and pelvic pain. MRI and CTC revealed an abnormal sigmoid colon from 42 to 50 cm above the anus, with digestive tract diameter reduced from 10 mm down to the virtual lumen, along with an overall rigid appearance. Laparoscopy revealed the extent of endometriosis lesions in the sigmoid colon and multiple implantations in the small bowel. We performed sigmoid and small bowel resection. This case demonstrates the obvious progression of deep rectal endometriosis despite 4 years of continuous hormonal therapy.