Alternatives aux prothèses mammaires

Breast sensibility after reconstruction: Comparison of different methods

BACKGROUND AND OBJECTIVES

Sensibility of the breast area is a key factor in quality-of-life evaluation after breast reconstruction (BR). Breast sensation can be assessed using numerous tools that are already largely described in the literature, including the Semmes Weinstein filaments which remain the most frequently used. Although different reconstruction techniques are available, post-BR sensitivity is rarely described. The aim of this study was to evaluate post-BR sensibility of the breast according to each reconstruction technique.

MATERIAL AND METHODS

Fifteen patients were included in each group, i.e. 90 patients in total: before BR, Latissimus Dorsi (LD) flap with implant, LD flap with fat grafting, exclusive fat grafting, Deep Inferior Epigastric Perforator (DIEP) flap, implant. A single evaluator assessed the sensibility with Semmes Weinstein filaments testing 7 zones on both sides. The native breast was considered as control. Various potential confounding factors were collected.

RESULTS

Patients who benefited from BR with fat grafting alone had a significantly better sensation of the reconstructed breast compared to the other groups (DIEP flap (P<0.0001), LD flap+implant (P=0.0013), LD flap with fat grafting (P=0.0073), implant (P=0.00315)). Comparing those results to the ones obtained in the group before reconstruction, only the fat grafting and DIEP flap groups showed a difference, the fat grafting group (P=0.0061) had higher sensibility whereas DIEP flaps were less sensitive (P=0.00233).

CONCLUSION

We compared mammary sensibility depending on the BR technique used. Our study is the first comparing breast sensitivity among all major breast reconstruction methods. Fat grafting resulted in better breast sensitivity in delayed breast reconstruction than implant or flap-based BR.

The Breast-Pectoralis Flap: A New Advance in Autologous Breast Reconstruction-A Preliminary Report on 20 Cases

BACKGROUND

In the past, several publications have described breast reconstruction techniques that utilize the contralateral breast; however, interest diminished because of technical difficulty, scarring, and poor aesthetic results.

OBJECTIVES

This study aimed to present a new breast reconstruction technique that uses a combination of the breast-pectoralis flap and the abdominal advancement flap.

METHODS

This retrospective study analyzed the results and complications of 20 consecutive breast reconstructions with the breast-pectoralis flap technique.

RESULTS

The authors present a series of 20 breast reconstructions that utilized the breast-pectoralis flap. Delayed breast reconstruction was performed in 13 cases (65%), breast reconstruction in 5 patients (25%) with Poland syndrome, sequela correction after a chest wall sarcoma in 1 patient (5%), and sequela correction after breast cystic lymphangioma resection in 1 patient (5%). One complication required surgical reintervention without long-term consequences. The outcomes were considered very good in 50% of the cases, good in 45%, and fair in 5%.

CONCLUSIONS

The combination of the breast-pectoralis flap and the abdominal advancement flap is an interesting advance in breast reconstruction. Evaluation of the presented cases suggests wider indications for this technique.

LEVEL OF EVIDENCE: 4

[Updated indications and techniques for immediate breast reconstruction, particularly in the case of adjuvant radiotherapy]

In 2023, 62,000 patients were diagnosed with breast cancer in France. Every year, 22,000 mastectomies are performed. Breast reconstruction (BR) should be an integral part of breast cancer management. Yet the MR rate in France is only 28% within 3 years of mastectomy, of which 14% are immediate breast reconstruction (IBR). The number of contraindications to RMI has steadily declined over the last few decades, although some of them remain definitive, such as inflammatory cancer (T4d). Today, many specialists involved in the management of breast cancer consider that IBR can be proposed in cases where adjuvant chemotherapy and/or radiotherapy is indicated, if it is not expected to delay carcinological management. The surgical team must then inform the patient of all available BR techniques. If a team does not offer a particular technique, the patient should be referred to a center that does. In all cases, the proposal for curative and reparative treatment should be the subject of a multidisciplinary discussion involving, in particular, a surgeon, a radiotherapist and a medical oncologist. When adjuvant radiotherapy is indicated, the patient must be informed of the increased risk of complications and deterioration of the aesthetic result. In this indication, RMI by prosthesis is a validated technique. However, if the patient has a history of radiotherapy, autologous techniques should be preferred. In a context of shared decision-making, the choice of whether or not to undergo MR and the type of technique must ultimately be made by the patient, in agreement with the multidisciplinary team.

The role of reconstructive surgery after soft tissue sarcoma resection

Soft tissue sarcomas are rare malignant tumors with pejorative prognosis. They require a multidisciplinary approach in a specialized hospital belonging to the NetSarc network in France. In all cases treated with curative intent, the objective of excision surgery is to achieve wide, microscopically negative margins (R0 according to the UICC classification). When growing on a limb, sarcomas may threaten functionally relevant structures and even lead to amputation. Nowadays, when combined with radiation therapy, wide exeresis limb-sparing surgery is achievable in 90 to 95% of the cases, of which 25% will nevertheless require reconstructive surgery to preserve the limb, to limit postoperative complications and to manage possible sequelae. Progress in reparative surgery, particularly in microsurgery, has helped not only to improve limb salvage rates but also to create wider margins without altering oncologic goals of curative resection. After determining the range of resection, reconstructive surgery should be tailored to address the tissue defect. The converse is to be strongly discouraged. The extent of resection must not be compromised or reduced in order to facilitate reconstructive surgery. A plastic surgeon must master all the flap techniques, including microsurgery, while taking into account the impact of preoperative and postoperative radiation therapy on previously irradiated tissues or on wounds requiring adjuvant therapy. Recent developments, especially as regards perforator flaps, have helped to enhanced the quality of reconstruction procedure while reducing donor site morbidity. In our experience, perforator flaps are a workhorse in reconstructive surgeries subsequent to soft tissue sarcoma of the extremities. On a parallel track, lipofilling (otherwise known as fat grafting or fat transfer) has become the first-line treatment for patients with post-surgical functional or cosmetic sequalae. It is performed after long-term follow-up during disease-free survival. Strict clinical examination and MRI are mandatory prior to programming any local procedure. Usually, three to four sessions of fat grafting are needed to enhance local trophicity or the cosmetic aspect. Sequalae treatments are of great interest in terms of psychological as well as functional outcome.

[Breast reconstruction with the autologous latissimus dorsi flap]

Amongst various techniques of breast reconstruction, Autologous Latissimus Dorsi (ALD) flap without breast implant is the newest technique that took advantage of recent improvement during the last decade. Surgical procedure is well standardized, and allows to harvest various fat areas attached to the muscle, to obtain an autologous reconstruction. Thoracodorsal pedicle is steady and makes ALD the most reliable flap that can be used in several indications, especially when DIEP or TRAM flap are inappropriate. Lipomodeling of the cleavage is performed during the first surgery. Additionnal lipomodeling is performed in the whole reconstructed breast area at 2 months to get the expected volume. In some cases, two lipomodelings may be required. Advantages of ALD flap are numerous such as its reliability, its trophicity, and a very low complications rate. After a learning curve, drawbacks are well controlled, since quilting suture of the donor site helped to reduce drastically seroma rate. Finally, ALD flap became the best technique, and the most used in our team for autologous breast reconstruction, and surpassed abdominal flaps such as TRAM flap or DIEP flap.

Fat Grafting to the Breast: Clinical Applications and Outcomes for Reconstructive Surgery

This article is a review of fat grafting for breast reconstruction. The use of small volume fat grafting for the correction of step-off deformities, intrinsic deformities, and extrinsic deformities of the breast, and the uses of large volume fat grafting for total breast reconstruction, correction of implant complications with simultaneous implant exchange with fat, and correction of noncancer chest wall deformities is reviewed. Cancer monitoring and the risks of cancer recurrence following fat-grafting to the breast is also reviewed.

[Breast implant-associated anaplastic large cell lymphoma. Case report of an undiagnosed form, management and reconstruction (ALCL)]

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.

[Autologous fat grafting to the postmastectomy irradiated chest wall prior to breast implant reconstruction: a series of 68 patients]

INTRODUCTION

After radiotherapy, breast reconstruction with an implant carries a high risk of failure and complication. Clinical and experimental studies have demonstrated that grafting adipose tissue (lipofilling) in an irradiated area enhances skin trophicity. Thus, we have started performing preliminary fat grafting to the irradiated chest wall prior to implant reconstruction in order to limit complications and failure risk.

PATIENTS AND METHODS

Patients were included in this study from 2007 to 2011. All patients had had mastectomy and irradiation for breast cancer. They all had one or more sessions of lipofilling prior to breast implant reconstruction. These patients were prospectively followed up in order to collect the following data: postoperative complications; cosmetic result; local breast cancer recurrences.

RESULTS

Sixty-eight patients were included. The mean number of fat grafting sessions was 2.3 (range 1-6). An average volume of 115mL (70-275) was injected each time. The mean volume of breast implants was 300mL (185-400). The mean follow-up was 23months (450). No breast cancer local recurrence was diagnosed during follow-up. Implant explantation was performed in one case (1.47%) The mean cosmetic result was 4.5/5.

CONCLUSION

Fat grafting to the irradiated chest wall prior to implant placement might be an alternative to flap reconstruction for patients who are not suitable or who refuse this option.

[Breast reconstruction after mastectomy]

The mutilating surgery for breast cancer causes deep somatic and psychological sequelae. Breast reconstruction can mitigate these effects and permit the patient to help rebuild their lives. The purpose of this paper is to focus on breast reconstruction techniques and on factors involved in breast reconstruction. The methods of breast reconstruction are presented: objectives, indications, different techniques, operative risks, and long-term monitoring. Many different techniques can now allow breast reconstruction in most patients. Clinical cases are also presented in order to understand the results we expect from a breast reconstruction. Breast reconstruction provides many benefits for patients in terms of rehabilitation, wellness, and quality of life. In our mind, breast reconstruction should be considered more as an opportunity and a positive choice (the patient can decide to do it), than as an obligation (that the patient would suffer). The consultation with the surgeon who will perform the reconstruction is an important step to give all necessary informations. It is really important that the patient could speak again with him before undergoing reconstruction, if she has any doubt. The quality of information given by medical doctors is essential to the success of psychological intervention. This article was written in a simple, and understandable way to help gynecologists giving the best information to their patients. It is maybe also possible to let them a copy of this article, which would enable them to have a written support and would facilitate future consultation with the surgeon who will perform the reconstruction.

Adipose-tissue grafting to the post-mastectomy irradiated chest wall: preparing the ground for implant reconstruction

INTRODUCTION

Breast implant reconstruction after radiotherapy carries a high risk of failure and complication. Nevertheless, it may be the only alternative for patients who are not suitable for autologous reconstruction or who refuse this option. As clinical and experimental studies have demonstrated that grafting adipose tissue (lipofilling) in an irradiated area improves the quality of the skin, we made the assumption that preliminary fat grafting of the chest wall might reduce the complication and failure rates of implant reconstruction by improving the implant coverage.

PATIENTS AND METHODS

From 2007 to 2009, 28 patients had fat transfer to the chest wall, prior to implant reconstruction. All patients had had mastectomy and irradiation for breast cancer. Lipofilling was initiated 6 months after the end of radiotherapy. The mean number of fat-grafting sessions was 2 (range 1-3). An average volume of 115 cc (70-275 cc) was injected each time. Once the chest wall's skin seemed to have gained enough thickness, implant reconstruction was performed.

RESULTS

The mean follow-up period was 17 months. Three minor complications occurred. Implant explantation was performed in one case for exposition. The cosmetic results were good and very good in >80% of the cases.

CONCLUSION

This study points out the benefits of fat grafting to the irradiated chest wall prior to implant placement and demonstrates that lipofilling prepares the ground to implant breast reconstruction. This approach could be considered as an alternative to flap reconstruction for selected patients.

[Complex breast reconstruction after severe chest trauma by firearm]

This case report is of a 47-year-old woman who suffered a ballistic chest trauma with severe left hemothorax and heart wound. She was treated in emergency for the collapse by heart surgery. Then the coverage for her soft thorax tissue loss was done by an ipsilateral musculocutaneous latissimus dorsi pedicled flap. The patient was subsequently addressed to our team for a repair, especially for reconstruction of the left breast. Initially, rehabilitation of aesthetics units breast was achieved through the realization of an abdominal advancement flap, and breast volume was restored by several sessions of lipomodeling. The surgical alternatives were very limited for this post-traumatic complex breast reconstruction. Due to ballistic trauma, no reliable recipient vessels allowed a microsurgical solution, and the ipsilateral latissimus dorsi was used for the coverage. In conclusion, the restoration of the aesthetics units with lipomodeling has achieved a very good result in this extreme thoracomammary region repair.

[Autologous fat grafting in radiated tissue prior to breast prosthetic reconstruction: is the technique reliable?]

BACKGROUND

Prosthetic breast reconstruction is critical in the radiated breast. The main purpose of this study was to determine whether fat grafting prior to breast reconstruction could improve thoracic tissue trophicity enough to perform a simple prosthetic reconstruction, avoiding a flap procedure.

PATIENTS AND METHODS

A total of 25 patients who had undergone a modified radical mastectomy followed by radiotherapy were retrieved. Fat was injected according to Coleman's technique. Prosthetic reconstruction was performed three to six months after the fat grafting procedure. Reconstruction of the nipple-areola complex was performed 3 months after implant positioning. Median follow-up interval was two years. Patient satisfaction was ascertained with a self-assessment questionnaire. Three independent blinded physician observers judged preoperative and postoperative photographs to determine the quality of reconstruction.

RESULTS

The mean refined fat injected volume was 160ml. In all cases except two, a unique fat grafting procedure was necessary. Prosthetic reconstruction was achieved in 23 cases. The technique failed in two cases and breast reconstruction was achieved by a latissimus dorsi flap with implant. During the follow-up interval, two complications occurred in two patients presenting with fat necrosis and oil cysts. The mean number of total surgical procedures was 2.5 per patient. Quality of reconstruction was judged as good by both physicians and patients.

CONCLUSIONS

Autologous fat grafting in radiated tissue prior to breast reconstruction is a safe and reliable technique. In selected cases, a simple prosthetic reconstruction can be achieved avoiding a flap procedure.

Lipomodeling of Poland's syndrome: a new treatment of the thoracic deformity

BACKGROUND

The severe forms of Poland's syndrome, with thoracic deformity, were until now very difficult to treat, with treatment involving complex surgery and implant insertion. Results were, in general, inadequate and the appearance unnatural. Our experience with fat transfer for breast reconstruction led us to propose reconstruction of the breast and thorax by serial fat transfer.

METHODS

Our patient had a very severe form of Poland's syndrome with agenesis of the pectoralis major and latissimus dorsi muscles and lack of fusion of the fourth costal arch. She was treated by fat transfer, or lipomodeling. Lipomodeling was developed in our team in 1998 to augment breast volume after autologous latissimus dorsi flap reconstruction. Because this technique and use of an implant were not possible, we attempted reconstruction by repeated lipomodeling. The patient underwent five sessions at intervals of a few months, the first in August 2001.

RESULTS

With 6 years of follow-up, the aesthetic, functional, and psychological results exceeded our expectations. In five sessions we were able to reconstruct a breast of natural shape, sensitivity, and consistency, and which was totally accepted by the patient. Mammography, echography, and MRI 1 year later showed a normal breast of fatty type.

CONCLUSION

Lipomodeling in Poland's syndrome is technically feasible. This original description of treatment of the severest form of Poland's syndrome, with impressive results and at the cost of limited constraints and scar sequelae, opens new perspectives and suggests extensive potential applications of lipomodeling in all disciplines related to the breast.

[Correction of breast Poland's anomalies. About eight cases and literature review]

PURPOSE

The objective of the present study was to analyze current indications and results of different methods for breast anomaly correction of Poland's syndrome.

PATIENTS AND METHODS

Eight patients with this deformity were operated between 1997 and 2008: seven females and one male. The mean age was 22. According to Foucras et al. classification, four patients revealed Poland's syndrome grade II, three patients grade I and two patients grade III. Three patients received silicone implants (two with Poland's syndrome grade II, one with grade III). Autologous fat injection was used for a male adolescent who was very embarrassed by his deformity. Controlateral lipo-aspiration was carried out in three cases with moderate Poland's syndrome breast asymmetry. For one patient, correction was achieved by controlateral breast resection.

RESULTS

No intraoperative or postoperative complications occurred for the eight patients. Aesthetic results were overall satisfactory.

CONCLUSION

The simplest and the fastest breast deformity correction technique in Poland's syndrome patients, the one with the least complications and cosmetic sequella and the most practiced by the surgeon, remains the best method for breast anomaly correction of Poland's syndrome.

[Breast volume reconstruction by lipomodeling technique: about 15 consecutive cases]

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.

[Efficacy of lipomodelling for the management of sequelae of breast cancer conservative treatment]

We report a study of 42 breast cancer patients undergoing lipomodelling, or fat transfer, for sequelae of conservative treatment. Detailed clinical and radiological data of the patients have been collected. These data demonstrate the feasibility of lipomodelling: the technique is simple but requires a learning curve to avoid cytosteatonecrotic lesions; the excellent results obtained in terms of shape and softness of the breast; no surgical implant or flap reconstruction is necessary; the reliability of the procedure: there is normal fat wasting within the first months after treatment, then results stabilize as the patient maintains a healthy weight; the small number of side-effects: only rare, predominantly infectious, rapidly resolving complications are induced. In conclusion, the fat transfer approach presented here represents a considerable advance for the management of moderate sequelae of conservative breast treatment. Using this technique makes it possible to restore the shape and softness of the breast better than any other surgical procedure before, particularly for patients with mild breast deformity.

[Fat tissue transplant: restoration of the mammary volume after conservative treatment of breast cancers, clinical and radiological considerations]

The aim of this study is to evaluate fat tissue graft as a treatment of sequelae of breast cancer conservative surgery.

MEANS AND METHODS

This prospective study during a nine-month period concerned 15 patients with breast cancer conservative treatment sequelae. Fat tissue has been injected at the site where the tumorectomie and subsequent radiotherapy had been performed. A mammographic and photographic checkup along with the patients' subjective evaluation were done before the operation and after the operation with a one-month, three-month, and nine-month follow-up. An objective analysis of the results was done by a panel from the pictures of the ninth month's follow-up. Preoperative and postoperative mammary volumes were calculated by a CT scan using a 3D program.

RESULTS

Mean fat tissue injected was 63.3cc. Mean patients' satisfaction grade was 8.1/10 at one month and 6.7/10 at nine months. The estimation of the resorption at nine months was 52.6% according to the patients while announced at 47.5% with the CT scan. Eighty percent of patients estimated the operation as "light" and 60% would be ready to have another injection. Skin tissue quality was enhanced and only one infection has been stated. Two-thirds of postoperative mammographies are still ACR 2 and one-third of the patients have had cytosteatonecrosis.

CONCLUSION

This fat tissue graft technique on irradiated skin for the correction of tumorectomy sequelae brings a simple and efficient solution, which is radiologically reliable and satisfying for the patients.

Expansion tissulaire et seins tubéreux: à propos de dix cas

INTRODUCTION

Tuberous breast is a deficiency of mammary development, principally in the lower lateral and medial quadrants. In types II and III of the Grolleau classification, we perform a two-stage correction by tissue expansion associated with an implant in order to avoid the double bubble deformity and the difficulty of medial infra-mammary fold reconstruction.

MATERIALS AND METHODS

Between February 2003 and February 2006, ten patients have been treated by implantation of an anatomical expander associated with a vertical and horizontal Puckett plasty. The second operation consisted in the replacement of the expander by an anatomical prosthesis associated, if necessary, with a second Puckett plasty and lipofilling.

RESULTS

There was no double bubble deformity. Three patients required a complementary lipofilling to improve the result of the lower medial fold. One prosthesis had to be repositioned and one expander infection was responsible of a three-month delay in the reconstruction procedure.

CONCLUSION

Tuberous breast correction is a therapeutic challenge in quite psychologically distressed patients. In types II and III, tissue expansion associated with a Puckett plasty increase the volume of the lower pole and reduces the risk of the double bubble deformity. The implantation of an anatomical prosthesis gives more natural effect to the contour of the glandular lower pole. This therapeutic attitude gives the chance of achieving a completely satisfactory result.

Fat grafting to the breast revisited: safety and efficacy

BACKGROUND

A 1987 American Society of Plastic and Reconstructive Surgeons position paper predicted that fat grafting would compromise breast cancer detection and should therefore be prohibited. However, there is no evidence that fat grafting to breasts is less safe than any other form of breast surgery. As discussions of fat grafting to the breast are surfacing all over the world, it is time to reexamine the opinions of the 1987 American Society of Plastic and Reconstructive Surgeons position paper.

METHODS

This is a retrospective examination of 17 breast procedures performed using fat grafting from 1995 to 2000. Indications included micromastia, postaugmentation deformity, tuberous breast deformity, Poland's syndrome, and postmastectomy reconstruction deformities. The technique used was the Coleman method of fat grafting, which attempts to minimize trauma and place grafted fat in small aliquots at many levels.

RESULTS

All women had a significant improvement in their breast size and/or shape postoperatively and all had breasts that were soft and natural in appearance and feel. Postoperative mammograms identified changes one would expect after any breast procedure.

CONCLUSIONS

Given these results and reports of other plastic surgeons, free fat grafting should be considered as an alternative or adjunct to breast augmentation and reconstruction procedures. It is time to end the discrimination created by the 1987 position paper and judge fat grafting to the breast with the same caution and enthusiasm as any other useful breast procedure.

Apport du bistouri à ultrasons dans la reconstruction mammaire autologue par lambeau de grand dorsal

OBJECTIVE

To study the ultrasonic energy dissection technique in breast reconstruction with the autologous latissimus dorsi flap and to evaluate its effect on seroma formation and other postoperative complications.

MATERIALS AND METHODS

Prospective monocentric study, between October 2003 and April 2004, including all the patients with breast reconstruction with the autologous latissimus dorsi flap performed with Ultracision Harmonic Scalpel. The patients were followed daily for one month and postoperative drainage volume, seroma formation, local infection or other wound complications were noted.

RESULTS

Twenty-one patients, aged 47 to 62 years old, underwent breast reconstruction with this technique. The median operating time was 74 minutes. The median drainage volume was 102.2 ml/day for the first week, 58.1 ml/day for the second week, and 28.4 ml/day for the third week. The last drain was removed at the 25th day postoperatively, half of the patients were drain free at the 20th day. No blood transfusion was necessary. The postoperative complications were dehiscent scars in two patients, with a wound infection in one case. Only one patient (4.8%) required two seroma punctures.

CONCLUSION

The ultrasonic energy dissection technique in breast reconstruction was found to be an interesting alternative to the conventionnal scalpel with less seroma formation and no additional disadvantages.

Reconstruction mammaire bilatérale par lambeau myocutanéograisseux de grand dorsal (31 cas consécutifs)

PURPOSE OF THE STUDY

The purpose of this study was to analyse the advantages, disadvantages and results of bilateral breast reconstruction by autologous latissimus dorsi flap.

MATERIAL AND METHOD

Thirty-one two-stage consecutive bilateral breast reconstructions were performed by the same operator between 1993 and 2001. All the reconstructions, in immediate or delayed manner, were indicated after radical or skin sparing mastectomy for breast cancer. We used the autologous latissimus dorsi flap for all cases. The reconstruction of the second breast was always delayed of a few months to avoid back's complications. We reviewed the charts of these patients retrospectively. Preoperative data, postoperative complications, dorsal seroma occurrence, morphological results and patient's satisfaction were evaluated. Median follow-up was 22 months.

RESULTS

The results confirm the procedure's reliability. Comparative rates of postoperative complications are not significantly different between first and contralateral breast reconstruction. Functional after-effects of bilateral latissimus dorsi harvesting are moderate. The aesthetics results have been judged as very good in 84% of cases and good in 16%. The satisfaction rate of the patients is high: 90,3% are pleased, 6,5% are satisfied and 3,2% are moderately satisfied.

CONCLUSION

The autologous latissimus dorsi flap allows a two-stage bilateral breast reconstruction. This procedure is not indicated for simultaneous bilateral breast reconstruction; it is the main drawback of this technique. So we believe that this procedure is an excellent alternative in all the indications of sequential bilateral breast reconstructions.