[Patients' satisfaction after immediate breast reconstruction: Comparison between five surgical techniques]. / Satisfaction des patientes après reconstruction mammaire immédiate : comparaison entre cinq techniques chirurgicales.

INTRODUCTION: The purpose of this study is to evaluate patients' satisfaction after immediate breast reconstruction (IBR) according to the surgical technique. METHODS: Included patients had an IBR between 2012 and 2017 and finished their reconstruction since a year. Patients were contacted by phone and their satisfaction was evaluated with the Breast Q questionnaire. According to the surgical technique, patients were divided into 5 groups: DIEP, gracilis, Latissimus Dorsi flap, definitive implant and expander implant. Techniques were grouped into two categories: free flaps and prothesis. Nipple reconstruction techniques were also evaluated: toe pulp grafting, nipple sharing and local flap. RESULTS: Nighty-five patients on the 103 who were eligible accepted to answer the questionnaire. Satisfaction with breasts was stastistically higher in the free flap group (72.6/100) than in the prothesis group (62.7/100) (P<0.01). Physical well-being (chest) was better for the free flap group than for the prothesis group (92.2/100 vs. 85.2/100, P=0.02). Nipple reconstructions with nipple sharing and free flap give a better satisfaction for patients than toe pulp grafting (75.3/100 and 73.5/100 vs. 47.8/100, P<0.01). CONCLUSION: IBR with free flap give, in a short time, a statistically higher satisfaction for breast than prothesis. Nipple reconstructions with free flap and nipple sharing give a better satisfaction too.

[Postoperative course after immediate breast reconstruction: Comparison between five surgical techniques]. / Les suites de la reconstruction mammaire immédiate : comparaison de cinq techniques chirurgicales.

INTRODUCTION: This study analyzes postoperative course of different immediate breast reconstruction techniques: deep inferior epigastric perforator flap (DIEP), gracilis, latissimus dorsi flap, expander implants and definitive implants. METHODS: All women operated on IBR between 2012 and 2017 in the CHU Strasbourg were included in this retrospective study. The main data collected were healing time, complications, surgical revisions and failure rates. These data were compared between the five IBR techniques to find a significant difference. Two groups were distinguished according to the surgical techniques: free flaps and implants. Data of those groups were compared too. RESULTS: One hundred and ninety three patients have had a breast surgical treatment between 2012 and 2017. Among them, 44 had a bilateral IBR (23%). Early and unserious complications, were less frequent in the implants group than in the free flaps group: 8.6% vs. 33.3% (P<0.01) for unilateral reconstructions and 10.9% vs. 38.9% (P<0.01) for bilateral reconstructions. No surgical failures were found in the free flaps group versus 6.2% for definitive implants and 3.6% for expander implants. Healing time was longer for the free flaps group than for the prothesis group: 5.6 weeks vs. 4.2weeks, (P<0.01). CONCLUSION: IBR with free flaps is associated with a higher risk for early and unserious complications as healing disorders, which extend the dressings time. However the failure rate is not higher with free flaps.

[Oncoplastic breast surgery]. / Chirurgie oncoplastique du sein.

Oncoplastic surgery is to treat breast tumors with the help of plastic surgery. Efficiency of breast-conserving treatments (BCT) compared to mastectomies is equivalent. BCT is better accepted but can cause breast deformity, thus further operations. Oncoplastic surgery aims at conserving an acceptable shape to the breast. It ranges from simple remodeling to more complex techniques modifying the width of the breast. According to the quadrant to treat (inner upper, outer upper, inner lower, outer lower, union of quadrants, tumors of the nipple-areola complex, tumors of the inframammary fold), according to the proximity of the tumor to the nipple, and to the size of the breast and tumor, various techniques are displayed. Few touch ups are necessary. Symmetry is managed during the initial operation or after.

Oncological safety of nipple-sparing prophylactic mastectomy: A review of the literature on 3716 cases.

INTRODUCTION: The objective of our study was to evaluate the risk of cancer after prophylactic nipple-sparing mastectomy (PNSM). MATERIAL AND METHODS: The PubMed database was consulted using the following key-words: "nipple-sparing mastectomy", "prophylactic", "locoregional recurrence", "oncological risk". Articles published between January 1995 and December 2016 were searched. RESULTS: Out of the 270 articles found, 19 were included. Overall, 15 studies were retrospective, 2 prospective, 2 prospective and retrospective and 3 were multicentric. All told, they involved 3890 patients corresponding to 6786 mastectomies, among which the total number of prophylactic nipple-sparing mastectomies was 3716. Average age of the patients was 44.4years and average follow-up was 38.4months (8-168months); 29.4% of them had a BRCA 1 or 2 mutation; 85 and 15% underwent prosthetic and autologous reconstructions, respectively. Average cancer rates exterior to and within the nipple areolar complex (NAC) were 0.2 and 0.004%, respectively. The overall average rate of histological pre-malignant lesions in the nipple areolar complex was 1.5%. The overall complication rate was 20.5%, and necrosis rates of the nipple areolar complex and the skin were 8.1 and 7.1%, respectively. CONCLUSION: In prophylactic breast surgery, conservation of the nipple areolar complex does not seem to increase the risk of cancer development. However, short follow-up time and the different methodologies applied in the different studies presently preclude generalization of the technique.

[The breast of the adolescent girl]. / Le sein de l'adolescente.

During adolescence, psychological and physical changes occur and breast takes a major place in the young woman body image. Except rare malign tumors, breast pathologies at this age are mainly benign or malformative. Malformative issues are revealed during breast growth, as isolated asymmetry or associated to other regional anomalies, with abnormal shape or volume of the breast, or even supernumerary breast. Therapeutic solutions will not differ from the ones used for adults. Breast lipofilling, recently admitted by plastic surgery community is an interesting tool that can be used on young women. Choosing the right technic depends on the initial problem. It comes at an early stage to offset hypoplasia resulting in a problem of asymmetry. It waits for breast stability in case of hypertrophy and for legal majority in case of breast augmentation using implants. Psychological impairment stays however a central issue and forces the surgeon to adapt to the individual and to his body change over time.

[Latissimus dorsi myocutaneous flap combined with implant in breast reconstruction: The technique of the dorsal bra]. / Reconstruction mammaire par lambeau musculocutané de grand dorsal avec prothèse : la technique du soutien-gorge dorsal.

The latissimus dorsi myocutaneous flap combined with an implant is an effective breast reconstruction solution especially in irradiated patients. The authors describe the specific technical aspects that allow them to optimize the results of this intervention. In the back, the skin paddle is drawn in the shape of a horizontal spindle so as to conceal the residual scar under the bra. In breast area, a J-shaped contraincision barring the mastectomy scar ensures a harmonious positioning of the skin paddle to the inferolateral part of the breast. After a 180° rotation, the latissimus dorsi muscle envelops the implant like a bra. Its upper edge is attached at the bottom to define the new submammary fold. Under the pectoralis major muscle, its distal end comes to fill the décolleté above the implant.

[Upper nasolabial flap: improving the surgical technique]. / Lambeau nasogénien à pédicule supérieur : vers une amélioration de la technique chirurgicale.

The upper nasolabial flap was initially described by Kilner in 1937, and popularized by Préaux in 1994. It is an interesting solution for the reconstruction of the ala thanks to its simplicity and reliability. Nevertheless, the results obtained with the original technique could be improved because of scars on the side of the nose and the absence of nostril groove. That is why we propose a modification of the surgical technique. We present the case of an 82-year-old female patient who presented with a basal cell carcinoma of the right nasal wing rebuilt by a modified upper nasolabial flap. The skin triangle above the defect, which separated it from the flap pedicle, was not sacrificed but dissected forward from behind, to the junction between the nasal dorsum and the lateral side of the nose. The next step, key step of our technique, was removing the epidermis from the flap pedicle. The nasolabial flap was thus slid forward to the alar loss of substance, thereby recreating a nostril groove nose with a single scar. The scar was thus more discrete than with the conventional technique. The other steps did not differ from the conventional technique. The immediate postoperative course was uneventful. Rebuilding a loss of transfixing matter of the ala with a modified Préaux flap technique allows obtaining a simple, reliable, and elegant reconstruction. It presents all the advantages of the conventional upper nasolabial flap with particular care given to the cosmetic appearance of nasal reconstruction.

[An original oncoplastic reduction mammaplasty technique for breast cancers with high risk of incomplete excision]. / Une technique originale de réduction mammaire oncoplastique adaptée aux cancers du sein à risque d'exérèse incomplète.

Oncoplastic reduction mammaplasty (ORM), like breast-conserving treatments for cancer, has a risk of incomplete excision, and sometimes requires complementary mastectomy. In that case difficulties may occur due to skin shortness induced by recent surgery. Review of bibliography brings evidence that some factors are predictive of incomplete excision. When a patient has one or more of these factors, surgeon should anticipate complementary mastectomy. Horizontal ORM should be reminded for they allow secondary mastectomy in a horizontal way to be performed. An adaptation of the inverted T pattern is proposed, also permitting mastectomy in a horizontal way. These solutions allow neither to alter skin healing nor to compromise the future breast reconstruction.

[Mammary metastasis of extramammary cancers: current knowledge and diagnostic difficulties]. / Métastases mammaires de cancers d'origine extra-mammaire: état des lieux et difficultés diagnostiques.

OBJECTIVES: Intramammary metastasis (IM) of non-breast cancers are infrequent. The purpose of this review of literature was to update the knowledge and explain diagnostic errors. PATIENTS AND METHODS: A review of literature with PubMed was used to select 54 articles published in English between 2003 and 2012. RESULTS: Melanoma (138 cases, 29.8%) were more frequently responsible of 463 cases of MIM, followed by lung, gynecological, gastrointestinal and hematologic cancers. IM occur mainly in women (92.2%), around 50 years, and are metachronous (84.2%). Clinically, they are usually round, painless, without skin retraction and associated with adenopathies (33%). In imaging, they are frequently single. Diagnosis, sometimes evoked by morphological study of the tumor, is confirmed by immunohistochemistry. Systemic metastasis are common, involving a shorter survival. DISCUSSION: The prevalence of primitive cancers is not alone responsible for the frequency of IM, as we can observe it with melanoma. The "seed and soil" hypothesis of Paget may explain it: some tumor cells grow preferentially in selected organs. Vascularity of the breast also seems to be an important factor. Clinically, IM can be confused with benign tumors. However, a history of cancer and multiple lesions should raise the suspicion of malignancy. In imaging, signs are non-specific. The morphological characteristics do not confirm the diagnosis with certainty. Immuno-histochemistry is fundamental, as the comparison with the histology of primary tumor. Support is mainly palliative.

[Poland's syndrome in women: Therapeutic indications according to the grade. Apropos of 11 cases and review of the literature]. / Syndrome de Poland chez la femme : indications thérapeutiques en fonction du stade. À propos de 11 cas et revue de la littérature.

INTRODUCTION: Correction of chest and breast abnormalities in Poland's syndrome differs among authors. The aim of this study is to discuss surgical protocols according to the grade of Poland's syndrome in women. PATIENTS AND METHODS: The authors present a series of 11 women with Poland's syndrome among which nine were operated. Several surgical techniques were used. Cosmetic results were analysed according to the treatment and grade. Median follow up is 9 years. RESULTS: In grade I, a round breast implant seems to be the best choice. In grade II, a latissimus dorsi flap combined with a breast implant gives better results than a breast implant alone. In grade III, breast and chest reconstruction are linked. The authors present a case of costal reconstruction followed by an expansion without a latissimus flap. CONCLUSION: Many authors recommend a latissimus flap combined with a breast implant in severe grades of Poland's syndrome. Using this flap is not always possible nor mandatory. According to soft tissue quality, expansion may be an alternative way or a temporary solution during growth.