Nicolas Leymarie

The role of Oncoplastic Breast Surgery in the management of breast cancer treated with primary chemotherapy

OBJECTIVEnThe purpose of this study was to evaluate the benefit of Oncoplastic Breast Conserving Surgery (BCS) compared to standard BCS after primary CT, in terms of oncologic safety and cosmetic outcomes.nnnBACKGROUNDnThe development of new drugs has led to greater use of primary chemotherapy (CT) for bulky breast cancer (BC) and has allowed wider indications for conservative surgery.nnnPATIENTS AND METHODSnWe identified 259 patients consecutively treated with BCS for primary BC from January 2002 to November 2010. All patients had undergone Oncoplastic Breast Surgery (OBS) or standard BCS after primary CT. Mastectomy rates, and oncological and cosmetic outcomes were compared.nnnRESULTSnA total of 45 OBS and 214 standard BCS were analyzed. The median tumor size was 40 mm in the two groups (p = 0.66). The median operative specimen volumes were larger in the OBS group than in the standard group (respectively, 180 cm3 and 98 cm3, p < 0.0001). Re-excision (9% vs. 2%) and mastectomy (24% vs. 18%) rates were similar (p = 0.22 and p = 0.30) in the standard BCS group and in the OBS group respectively. At a median follow-up of 46 months, local relapse (p = 0.23) and distant relapse (p = 0.35) rates were similar.nnnCONCLUSIONnOBS allows excision of larger volumes of residual tumor after primary CT. OBS outcomes results were similar to those of standard BCS. Oncoplastic Breast Conserving Surgery (BCS) after primary chemotherapy allows wider breast resection than standard BCS. Survival and relapse probabilities are similar in both groups.

Factors influencing the decision to offer immediate breast reconstruction after mastectomy for ductal carcinoma in situ (DCIS): The Institut Gustave Roussy Breast Cancer Study Group experience

BACKGROUNDnThe increased rate of ductal carcinoma in situ (DCIS) is associated with a rise in indications for mastectomy and immediate breast reconstruction (IBR). The purpose of our study was to evaluate the factors affecting the indications for IBR and its modalities.nnnSTUDY DESIGNnData concerning two hundred and thirty-eight consecutive patients with DCIS who had undergone modified radical mastectomy and a sentinel lymph node biopsy (SLNB) between 2005 and 2011 were extracted from our database. We then conducted a comparative study between patients who had undergone IBR and those who had not, to determine which factors affected the decision to offer IBR (LOE II).nnnRESULTSnAbout 57.1% had IBR and 42.9% had no reconstruction. The most common reason why IBR had not been performed was that it had not been proposed by the surgeon (33.4%). Of the 136 patients offered IBR, an implant had been proposed to the majority of them (81.6%). The IBR rate was highest among women under 50 years (52.2%), and was lower among women with diabetes (0.7%) or obesity (8.8%). The choice of reconstruction was not affected by tobacco use or positive SLNB results.nnnCONCLUSIONnFactors predictive of the IBR reflect the influence of surgeon counselling and, to a lesser extent, consideration of patient comorbidities. However, there is a need to improve patient information and physician referral.

Modification of flap design for total mobile tongue reconstruction using a sensitive antero-lateral thigh flap

Reconstruction of large carcinologic tongue defect is mandatory to recover adequate speech and swallowing. Free flaps provide thin and pliable tissues needed to restore the shape and the volume of the tongue but their functional outcomes, especially in case of total mobile tongue reconstruction, are still limited. The authors describe a modification of flap design called the cathedral triptych used with the antero-lateral thigh flap. This modified design recreates a near normal neotongue shape with more projected tip and vertical bulk that can contact the palate and the upper lip. Ten patients underwent total mobile tongue reconstruction with a sensitive antero-lateral thigh flap and a cathedral triptych design. This modification of flap shaping and folding optimises postoperative oral function.

Axillary Padding without Drainage after Axillary Lymphadenectomy – a Prospective Study of 299 Patients with Early Breast Cancer

Background: After lymphadenectomy for early breast cancer, seroma formation is a constant event requiring a suction drainage. This drainage is the strongest obstacle to reducing the hospital stay. Axillary padding without drainage appears to be a valuable option amid the various solutions for reducing the hospital stay. Methods: We conducted a comparison between 114 patients with padding and 185 patients with drainage. Data were obtained from 2 successive prospective studies. Results: The mean hospital stay was 2.4 days (range 1–4) in the padding group and 4.2 days (range 2–9) in the drainage group (p < 0.05). There were fewer needle aspirations for seroma in the padding group (8.8 vs. 23%, p < 0.05). At 6 weeks, only 28% (32/114) of the patients in the padding group reported pain versus 51% (94/185) in the drainage group. The mean pain intensity at 6 weeks was 3 and 4.3 respectively (p < 0.0001). Conclusion: Axillary padding without drainage was associated with a better post-operative course than suction drainage in this historical comparison, and the hospital stay was significantly shortened. There are only few series published on this new technique but they all indicate good feasibility and good tolerance. A large randomised multicentric evaluation is now warranted.

Reconstruction of large mandibulofacial defects with the composed double skin paddle fibula free flap: a review of 32 procedures.

The purpose of this study was to analyze our experience with the composed double skin paddle fibula free flap to reconstruct large mandibulofacial defects.

Cervicothoracic reconstruction with an anteromedial thigh flap: A novel flap concept *

The anteromedial thigh region is more popular as a donor site for skin graft than for flap. It is an extended area whose limits are poorly defined. This explains why flaps vascularised by different source arteries but described under the same name can be found in the literature introducing confusion and misunderstanding. This confusion was introduced since the primary descriptions as Baek presented in 1983 an anteromedial skin flap whose source artery was the superficial femoral artery and Song published a year later, under the same name, a flap vascularised by the innominate descending branch of the lateral circumflex femoral artery. Whatever the name and the source artery, the anteromedial thigh region is an under-exploited region which can be useful in the case of composite and complex defects. Anteromedial thigh flaps, either as pedicled or as a microvascular free-tissue transfer, were used in reconstructive surgery. We here describe a chimeric flap of the anteromedial thigh region and used as a flow-through flap.

Utilisation du vert d’indocyanine en chirurgie sénologique et reconstruction mammaire

The Indocyanine green (ICG) is a soluble dye that is eliminated by the liver and excreted in bile. When illuminated by an near-infrared light, the ICG emits fluorescence in the near-infrared spectrum, which can be captured by a near-infrared camera-handled device. In case of intravenous injection, ICG may be used as a marker of skin perfusion. In case of interstitial injection, it may be useful for lymphatic network mapping. In oncological and reconstructive breast surgery, ICG is used for sentinel lymph node identification, to predict mastectomy skin flap necrosis, to assess the perfusion of free flaps in autologous reconstruction and for diagnosis and treatment of upper limb secondary lymphedema. Intraoperative indocyanine green fluorescence might also be used to guide the excision of nonpalpable breast cancer.

Reconstruction mammaire autologue par lambeau perforant lombaire

Even though DIEP-SIEA flaps or latissimus dorsi musculocutaneous flap are the most frequently used, a wide variety of flaps have been described for autologous breast reconstruction. Concerning the choice of donor-site, the aim is to prevent and to limit the morbidity. That is why the donor-site should be carefully chosen, according to the morphology of the patient. Lumbar artery perforator flap (LAP) is an option for breast reconstruction, but it is not well known and its use is limited. This study summarizes the authors early experience with free LAP flap for breast reconstruction. Three patients underwent immediate or delayed autologous breast reconstruction using a LAP flap. No vascular by pass was required to lengthen the pedicle. No partial or complete flap necrosis has been reported. There was no surgical donor-site complication. Mean operative time was 7hours. LAP flap can be considered as a good option for autologous breast reconstruction, especially in patients with unfavorable abdominal donor-site, and impossibility to use a DIEP flap.