G. Toussoun

Breast fat grafting (lipomodelling) after extended latissimus dorsi flap breast reconstruction: a preliminary report of 200 consecutive cases.

BACKGROUND The efficacy of fat grafting has long been a controversial issue. Breast lipomodelling after extended latissimus dorsi flap reconstruction was first attempted at the Plastic and Reconstructive Surgery unit of Leon Berard Cancer Centre in 1999. We present the results of a retrospective report of the first 200 consecutive patients treated at our institution from 1999 to 2003. METHODS We identified specific requirements of the patients, and collected information on the surgical techniques used and the volumes of fat tissue injected. We analysed and compared the results of a total of 244 lipomodelling sessions. RESULTS The graft consisted of 70% fat graft, 13% oily supernatant and 17% serum residues. Approximately 30% was lost during centrifugation. On average, 176 ml of fat were injected in each breast. Very satisfactory results were obtained in 94.5% of the cases, with a majority of patients (80%) being very satisfied with the procedure and only 1.5% complications. CONCLUSION Our results demonstrate the safety and feasibility of breast lipomodelling. It is a new approach to improve reconstructive outcome after extended latissimus flap breast reconstruction.

Reconstruction mammaire par transfert graisseux exclusif : à propos de 15 cas consécutifs

UNLABELLED BACKGROUND OF STUDY: The purpose of this prospective study is to detail the preliminary results, the advantages and drawbacks of a new iterative fat transfer protocol in selected breast reconstructions. MATERIAL AND METHODS Fifteen patients had breast reconstruction following mastectomy for breast cancer by this iterative lipomodeling protocol, between 2002 and 2007. Clinical and technical aspects are described. Indications, advantages, drawbacks, complications and morphological results are discussed. RESULTS Mean age at first stage procedure was 50 years (min: 41, max: 57). Indications were eight delayed breast reconstructions, three salvage reconstructions after flap failure, two restorations following primary chest wall reconstruction, two immediate breast reconstructions. Two to five sequential procedures were necessary to obtain a satisfactory breast volume (mean: three procedures). Mean total transferred fat volume was 600 cm(3) (min: 266 cm(3), max: 926 cm(3)). Multiple procedures were performed: restoration of breast skin envelope by abdominal advancement fasciocutaneous flap, breast contours liposuction, controlateral breast symmetrisation, nipple areola complex reconstruction. Mean follow-up was 28 months. The aesthetics results have been judged as very good in 10 patients, good in four patients and poor in one patient. The satisfaction rate of the patients is high: 10 patients are pleased, four patients are satisfied and one patient is moderately satisfied. CONCLUSION Fat transfer alone can efficiently restore breast volume after mastectomy, granting all advantages related with autologous reconstruction. No donor site morbidity is present; in fact some secondary benefits are observed thanks to the correction of eventual disgraceful lipodystrophies. These secondary benefits strengthen patient compliance improving iterative procedures tolerance. Lack of available adipose tissue and high breast volume are the major morphological limits of the technique. In our experience, fat transfer appears to be a promising technique for breast reconstruction. Long term results still have to be evaluated before it can become a standard.

Percutaneous fasciotomies and fat grafting: indications for breast surgery.

BACKGROUND The management of breast deformities can be very difficult in the presence of breast shape retraction. Percutaneous fasciotomies, which release fibrous strings, can be a very useful tool for shape improvement in the recipient site for a fat graft. OBJECTIVES The authors evaluate the efficacy of fasciotomies in association with fat grafting in breast surgery. METHODS A retrospective chart review was conducted for 1000 patients treated with concurrent fasciotomies and fat grafting between January 2006 and December 2011. The recipient site was prepared with fasciotomies, and fat was harvested from other parts of the body using a low-pressure 10-mL syringe lipoaspiration system. Fat was centrifuged and injected into the breast for reconstruction or chest deformities. The postoperative appearance of the breast scars was scored by both the surgeon and the patient. Each complication was recorded, including instances of hematoma, infection, tissue wounds, scar healing, and fat necrosis. RESULTS In this series of patients, for whom the primary indications for the procedure were sequelae of breast-conserving surgery after cancer, latissimus dorsi flap breast reconstruction, breast implant reconstruction, tuberous breast, Poland syndrome, and funnel chest, we recorded the following complications: 0.8% local infections (8/1000), 0.1% delayed wound healing that required medical care (1/1000), and 3% fat necrosis (31/1000). Fasciotomy scarring was considered minor by the patient in 98.5% of cases and by the surgeon in 99% of cases at 1 year postoperatively. CONCLUSIONS Fat grafting is a safe and reliable technique that improves the aesthetic outcomes of breast surgery. Percutaneous fasciotomies provide excellent aesthetic results and an improvement in breast shape with no scarring. In our experience, both fat grafting and fasciotomies offer a durable result over the long term.

Breast Amputation Correction of a Horse Bite Using the Lipomodeling Technique

UNLABELLED Mammary gland development is an important phase of puberty, and it marks the passage into adulthood for women, so any trauma leading to mammary deformities has an important physical and psychological impact. Often, classic techniques are difficult to use in the treatment of traumatic breast lesions. In this article, the authors present an exceptional case of breast reshaping by lipomodeling in a teenage patient who had experienced a horse bite. Treatment included 2 fat grafting sessions with fasciotomies, nipple reconstruction using a bifoliated flap, and areolar tattooing, all without any complications. We achieved a satisfactory result with a symmetric volume, a natural tissue consistency, and sensation improvement, all of which were maintained as the patient grew. In our experience, fat transfer was a safe and reliable technique that provided a good and stable aesthetic result, improving the volume and shape without additional scarring or implant devices. LEVEL OF EVIDENCE 5.

Skin-Reducing Mastectomy in Immediate Reconstruction: How to Limit Complications and Failures

Background In hypertrophic and/or very ptotic breasts, skin-reducing mastectomy (SRM) is challenging and the risk of complications is high. Few publications have reported the use of an autologous latissimus dorsi flap (ALDF) in this indication. Most studies opt for implant reconstructions, with a high failure rate. Objectives We aimed to identify and present the technical refinements that reduce the risk of reconstruction failure in patients with hypertrophic and/or ptotic breasts with breast cancer or at risk of breast cancer after SRM with immediate breast reconstruction (IBR) utilizing an ALDF. Methods Our retrospective study, covering a period of 18 years, included a series of 60 patients with hypertrophic and/or ptotic breasts who underwent 67 SRM and IBR procedures utilizing an ALDF. The complications were recorded and the risk factors analyzed. Results Sixty-seven SRMs were reviewed. Forty-nine procedures were performed with an inverted-T scar technique and 18 with a vertical scar technique. The nipple-areola complex (NAC) was preserved in 10 cases. There were eight (11.9%) cases of minor mastectomy flap necrosis after skin-reducing reconstructions, 16 (23.8%) wound dehiscences, no infections, no breast seromas, and no reconstruction failures. Smoking increased the risk of minor mastectomy flap necrosis (P = 0.048) and wound dehiscence (P = 0.002). Previous radiotherapy was associated with minor mastectomy flap necrosis (P = 0.001). Conclusions The use of an ALDF together with technical refinements that preserve the vascular supply of the skin envelope leads to successful IBR with consistently good aesthetic results. Above all, it avoids failure of the reconstruction in very large or ptotic breasts. Level of Evidence 4

Fat Transfer in Oncoplastic and Reconstructive Breast Surgery

Fat grafting has become an important part of the modern armamentarium for treating women with breast cancer. It has numerous applications in the oncoplastic and reconstructive arena to help optimize cosmesis, enhance symmetry and improve tissue quality which has been adversely affected by scaring or radiotherapy. Fat transfer in breast surgery is not a new concept, but technical refinements, improved understanding of its potential roles and reassurance about its oncological safety have seen the technique move into the mainstream of breast practice in recent years. Nano- and micro-fat grafting, fat transfer, fat injection and lipofilling, lipomodelling and even liposculpture are all terms used to describe the use of fat to surgically reconstruct defects and rejuvenate the breast by improving or changing the contour and shape, improve the consistency and enhance the volume of the breast. This chapter will review the indications and uses, contraindications, adverse effects, oncological safety and techniques of lipomodelling in the field of breast surgery.

Pyoderma gangrenosum: an exceptional complication of venous access device.

Introduction Pyoderma gangrenosum (PG) is a rare disease whose precise etiology remains unknown. It causes rapidly developing skin necrosis and can occur after surgery, or after a nonspecific external stimulus. This condition is difficult to diagnose because it often mimics a fulminant infection. Clinical case We present a case of very significant local presentation of PG after placement of a venous access device. Fifteen days after placement, the patient developed extensive cutaneous ulcers and necrosis in the subclavicular area, which led to the misdiagnosis of infection. The device was removed and the patient was given antibiotics. Because there was no improvement following antibiotic treatment, combined with the worrying and extensive appearance of the skin and extremely intense pain, the diagnosis of PG was made. The patient was immediately treated with high-dose corticosteroids, resulting in rapid improvement of the lesions and relief of pain. Conclusion PG should be considered in cases of extensive, antibiotic-resistant ulceration and treatment with corticosteroids should be initiated. Clinical improvement is usually dramatic, with almost immediate suppression of the pain and arrest of the lesions progression. Early treatment is the best guarantee for an effective recovery.

Full thickness thoracic wall reconstruction after oncologic surgery

ObjectivesThoracic wall reconstruction after oncologic resection remains a complex form of surgery that implies a multidisciplinary approach. The purpose of this study is to present our experience in full thickness thoracic wall reconstruction after tumor resection.MethodsA retrospective study, including patients who were operated for full thickness thoracic wall defects after tumor resection, was undertaken. The type of bone and soft tissue reconstruction and the patient outcome was evaluated.ResultsBetween 1998 and 2011, a total of ten patients underwent full thickness thoracic wall resection and reconstruction. All patients were reconstructed during a single-stage surgery. In all cases, bone reconstruction was accomplished by a polytetrafluoroethylene patch (Gore-Tex), while soft tissue reconstruction required either muscle or musculocutaneous pedicled flaps such as latissimus dorsi, rectus abdominis, or pectoralis major flaps. In this series, no major complications (infection, respiratory or cardiac failure, or deaths) were detected.ConclusionsUsually treated as palliative surgery, thoracic wall resection and immediate reconstruction allows large wall resection which, in association with adjuvant therapy, can potentially cure patients who have had a primary tumor or a unique metastasis.Level of Evidence: Level IV, therapeutic study.