Latissimus dorsi seroma prevention with running quilting suture using barbed suture.

Dorsal seroma is a common complication of autologous latissimus dorsi flap (ALDF) in breast reconstruction, and has limited the use of this technique, despite its aesthetic success. It is important to find a right technique to limit the incidence of seroma formation after ALDF. The aim of this study was to evaluate the effectiveness and tolerance of a dorsal quilting technique called "running quilting" using barbed resorbable suture in seroma prevention. Three hundred patients who underwent ALDF breast reconstruction in the period between 2004 and 2014 were included in this study. The population was divided in 3 groups; without quilting, with simple quilting suture, and with running quilting using barbed suture. The incidence of small seromas (requiring 1 or 2 aspirations during routine postoperative visits without adding additional appointments to the follow-up routine) was not significantly decreased: it was 54% in the non-quilted group, 47% in group 2 Quilting, and 34% in group 3 running quilting. However, quilting reduced the duration of drainage, and the rate of late seromas (from 8% to 0%), and chronic sero-hematomas completely disappeared in our experience. Running quilting using barbed suture is highly effective in preventing late and refractory donor-site seromas. Its effectiveness is expected to increase the use of ALDF in breast reconstruction, which we consider currently as one of the best autologous reconstruction techniques.

An anatomic study of deep inferior epigastric artery diameters at the origin from external iliac and at the lateral border of rectus abdominis muscle by computed tomographic angiography from autologous breast reconstruction patients.

BACKGROUND: Autologous breast reconstruction by means of microsurgical abdominal flaps is an very well described technique. The flap harvest dissection under inguinal ligament would cause the risk of parietal weakening in this zone and postoperative bulging. The goal of our study is to investigate whether the deep inferior epigastric artery diameter remains constant from its exit of the external iliac artery to its entrance in the rectus muscle sheath. PATIENTS AND METHOD: One hundred arteries were studied on fifty preoperative computed tomographic angiographies made before a DIEAP flap for breast reconstruction. We measured the caliber of the left and right deep inferior epigastric arteries at these two landmarks. The length of this artery between these was also calculated. This data were collected with specific angiography reconstruction. RESULTS: At the caudal landmark, the mean DIEA diameter was 2.1±0.27mm on the left side and 2.1±0.31mm on the right side. At the cephalic landmark, the mean DIEA diameter was 2.0±0.28mm on the left and 2.0±0.27mm on the right side (P=0.00035 at left side; P=0.0089 at right side). The mean pedicle length between the two landmarks was 22.3±2.85mm on the left side and 22.2±2.98mm on the right side. CONCLUSION: This computed tomographic angiography study showed that the diameter of DIEA is equivalent at its origin and at the lateral border of muscle. Flap harvest without dissection under inguinal ligament provides sufficient pedicle length and caliber to allow for comfortable and reliable sutures.

[Incisions and baseline operative technique of cervicofacial lifting]. / Incisions et technique opératoire de base du lifting cervicofacial.

Cervicofacial lifting is one of the most iconic procedure of plastic surgery and is about hundred years old. In the following chapters of this report, numerous technical points will be specify. A baseline reliable and reproducible technique, appealing to the largest possible audience is presented in order to begin this surgery in optimum conditions. Pre- and postoperative management is also exposed. The aim of this chapter is to precise incisions and baseline operative technique of cervicofacial lifting, with description of SMAS and platysma suspensions as well as complementary procedures like liposuccion and lipofilling. This chapter will lay the foundation of more complex elements that will be described in the various following chapters.

Nipple reconstruction using rib cartilage strut in microsurgical reconstructed breast.

Nipple areolar reconstruction is the very last step of breast reconstruction. It is of outmost importance because it gives final appearance of breast, which is then better integreated by the patient in her body image. A lot of techniques are described to recreate nipple projection, from trompe l'œil tattoo to local flap, nipple sharing or autologous tissue graft. Common drawback of these techniques is nipple flattening with time, due to tissue atrophy. We present here a technique to use rib cartilage graft as structural framework for nipple reconstruction. Rib cartilage is stored in a pocked created in the groin during first step of breast microsurgical reconstruction. During nipple-areolar reconstruction, graft is cut at appropriate size and used inside a C-V flap to enhance nipple projection. Results show excellent symmetry and projection and is stable over time. Patients are very satisfied and can better integrate their new breast.

[Correction of thoraco-mammary deformity of Poland syndrome]. / Correction de la déformation thoracomammaire du syndrome de Poland.

Breast deformity of Poland syndrome is a malformation known to be difficult to treat. Numerous descriptions of surgical corrections have been published but none achieved to correct severe cases before description of lipomodeling technique. The aim of this article is to present thoraco-mammary deformity of Poland syndrome, corrections techniques already available and therapeutical indications in primary and secondary cases. Constant anomaly of Poland syndrome is agenesis of sternocostal part of pectoralis major muscle but other muscular anomalies can be associated. Skin and glandular anomalies present with a fine skin and an absent or hypoplasic subcutaneous fat with a glandular hypoplasia of various degree. Osteo-cartilaginous anomalies can be associated in very severe cases. Clinical sign of Poland syndrome is forced adduction maneuver highlighting pectoralis major agenesis. Functional impact of the deformity is low but psychological and psychosocial implications can be very important, supporting an early surgical correction. Therapeutic means are various and accurate descriptions are given in this article: thoracic bony reconstruction, thoracic implant made of silicone elastomer, breast implant, skin expansion, latissimus dorsi pedicled flap, free flaps, breast lipomodeling, breast-pectoralis flap. Principles of each technique are described and balanced with their actual use in this malformation. Indications have been completely modified these last years due to lipomodeling contribution which represented a huge step in this deformity treatment. In our practice, if autologous reconstruction with lipomodeling is possible, we choose this solution at first. In case of severe thoracic deformity, a silicone elastomer implant made with the help of computed assisted conception can be an important adjunct, mainly by thin young man. In secondary cases, if implant is well tolerated, we found logical to stay in the same reconstruction path and do one or two sessions of lipomodeling in order to improve reconstruction. If implant tolerance is low and skin very thin at risk of exposure, we do recommend a conversion of implant reconstruction to autologous reconstruction. In conclusion, thoraco-mammary deformities of Poland syndrome are rare and hard to treat and should be managed by well trained and experimented surgeons. Breast lipomodeling is a huge step in the treatment of these deformities and should be regarded, in our opinion, as first line treatment if fat deposits are sufficient. In case of low fat provisions or in the thin young man, composite techniques should be used with silicone elastomer implant.

[Breast implant-associated anaplastic large cell lymphoma. Case report of an undiagnosed form, management and reconstruction (ALCL)]. / Lymphome anaplasique à grandes cellules associé aux implants mammaires (LAGC-AIM). Présentation clinique d'une forme initialement non-diagnostiquée, prise en charge et reconstruction.

Breast implant-associated anaplastic large cell lymphoma (ALCL) is an extremely rare disease. Is a new nosologic entity with a multifactorial origin and a wide occurrence delay after breast implantation. This article reports the case of a 60 years old patient with a progressive swelling of the right breast after aesthetic breast implants. Diagnostic was delayed because first surgeon was not familiar with the disease. Patient was then referred to us for management. We performed an implant removal and a complete capsulectomy. Pathologic report confirms the diagnostic. After one year and normal ultrasound evaluation, we reconstructed the breast with lipomodeling and mastopexy. Contralateral implant was also removed at time of reconstruction. Vast majority of breast implant-associated ALCL occurs at a time lapse of 11 to 15 years after implant augmentation, with a mean age of 63 years. Among the worldwide 173 cases reported in March 2015, smooth implants seem not to be at risk but 80% of cases were associated with macrotexturized implants. Clinical presentation and diagnostic tools are more and more published but there is to date no recommendation concerning reconstruction delay after implant removal for this pathology. We advise the realization of a breast ultrasound every three months during the first year and wait for a one-year period before reconstruction. In case of aesthetic surgery, mastopexia can be done to allow for glandular shaping. Lipomodeling is an excellent technique to correct the lack of volume due to implant removal. In case of reconstructive setting, implant can be replaced by flap procedure with lipomodeling if needed or lipomodeling alone if recipient site is favorable and patient has enough fat tissue. Contralateral implant should be removed during reconstruction time.

Development of a cost-effective method for platelet-rich plasma (PRP) preparation for topical wound healing.

Platelet-rich plasma (PRP) is a volume of plasma fraction of autologous blood having platelet concentrations above baseline whole-blood values due to processing and concentration. PRP is used in various surgical fields to enhance soft-tissue and bone healing by delivering supra-physiological concentrations of autologous platelets at the site of tissue damage. These preparations may provide a good cellular source of various growth factors and cytokines, and modulate tissue response to injury. Common clinically available materials for blood preparations combined with a two-step centrifugation protocol at 280g each, to ensure cellular component integrity, provided platelet preparations which were concentrated 2-3 fold over total blood values. Costs were shown to be lower than those of other methods which require specific equipment and high-cost disposables, while safety and traceability can be increased. PRP can be used for the treatment of wounds of all types including burns and also of split-thickness skin graft donor sites, which are frequently used in burn management. The procedure can be standardized and is easy to adapt in clinical settings with minimal infrastructure, thus enabling large numbers of patients to benefit from a form of cellular therapy.

Le plasma riche en plaquettes (PRP) est un volume de la fraction plasmatique du sang autologue ayant des concentrations au-dessus des valeurs de base des plaquettes sang total en raison de l'élaboration et de la concentration. Le PRP est utilisé dans différents domaines de la chirurgie pour améliorer la guérison des tissus mous et des os en délivrant des concentrations supraphysiologiques de plaquettes autologues au niveau du site de lésion tissulaire. Ces préparations peuvent fournir une bonne source cellulaire de divers facteurs de croissance et, de cytokines et moduler la réponse tissulaire à une lésion. Des matériaux communs cliniquement disponibles pour des préparations hématiques en association avec un protocole de centrifugation en deux étapes à 280g chacun, afin d'assurer l'intégrité des composants cellulaires, ont fourni des préparations de plaquettes qui ont été concentrées 2-3 fois par rapport aux valeurs de sang total. Les coûts se sont avérés inférieurs à ceux des autres méthodes qui nécessitent un équipement spécifique et des jetables ayant un coût élevé, tandis que la sécurité et la traçabilité peuvent être augmentées. Le PRP peut être utilisé pour le traitement de tous les types de lésions, y compris les brûlures comme aussi pour le traitement des sites donateurs de greffes cutanées d'épaisseur variable, qui sont fréquemment utilisées dans la gestion des brûlures. La procédure peut être standardisée et facilement adaptée dans les milieux cliniques avec une infrastructure minimale, permettant ainsi à un grand nombre de patients de bénéficier de cette forme de thérapie cellulaire.