Breast base anomalies: treatment strategy for tuberous breasts, minor deformities, and asymmetry

A variety of breast deformities of differing appearances can be grouped together within an extensive syndrome that is characterized by anomalies of the breast base and preferentially involves the lower quadrants. Tuberous breasts are the most typical, but not the only, form of the deformity. The authors studied a series of 37 patients who had breast surgery, and they used a classification of three types: I, II, and III (in increasing order of severity). In type I breasts (minor form), only the lower medial quadrant is deficient; in type II breasts, both lower quadrants are deficient; and in type III breasts, all four quadrants are deficient. The study showed a predominance of minor forms (54 percent of breasts operated on) and of combinations including at least one minor form (81 percent of patients). Seventy percent of women had a breast asymmetry of more than 100 g. Only 27 percent of breasts operated on were hypotrophic, 45 percent were of normal volume, and 28 percent were hypertrophic. The authors propose a procedure to treat the minor forms of the deformity, using a mammaplasty with a superior pedicle and a lower lateral dermoglandular flap to fill the deficient lower medial quadrant. They define the indications of the classic techniques according to the type of deformity and stress the frequent need for secondary revision.

["Saphenous vascular loop" technique in the treatment of lower limb defects. Report of five cases]

Five patients with high energy trauma of the lower limb with tissue defect located in the knee or the proximal third of the leg underwent reconstruction with a free latissimus dorsi flap. This flap was connected to a vascular saphenous loop which initially creates an arterioveous shunt between proximal femoral vessels. This was performed in a single operation with two teams of surgeons. This technique was chosen because a healthy recipient pedicle was not available in the vicinity of the defect. Application of vein grafts is not the usual procedure but there are situations in which it becomes necessary. Our aim in this paper is to discuss these situations, to describe the technique used in our Hospital and to analyze the advantages and disadvantages of a one or two-stage operation.

[Breast reconstruction after mastectomy for cancer]

In spite of advances in breast cancerology, partial or total mastectomy still has wide indications and remains a mutilative procedure. Since its introduction over thirty years ago, breast reconstruction has become an accepted, codified and efficient procedure. The techniques which can be used can be broadly divided into two categories: reconstructions with implants, which have been greatly improved by skin expansion techniques, and reconstructions using myocutaneous flaps. Whatever method is used, the breast is modeled during the reconstruction procedure and surgery is frequently necessary to obtain a symmetric opposite breast; a good knowledge of plastic surgery is thus a requisite.

[Effect of irradiation fields on the results of breast reconstruction with skin expansion after radiotherapy]

Deferred prosthetic breast reconstruction after skin expansion is considered to be difficult after radiotherapy. The authors report a series of 14 cases of reconstruction after radiotherapy, compared with 6 cases of reconstruction without radiotherapy. They reported a similar quality of results after radiotherapy not including irradiation of the chest wall and in the absence of radiotherapy (p = 0.742). On the other hand, a significant deterioration of the results was observed when radiotherapy included chest wall irradiation (p = 0.0015). Finally, no direct correlation was observed between the macroscopic appearance of the skin and presence or absence of a history of irradiation of the chest wall. They conclude that the indications for reconstruction by tissue expansion after radiotherapy must be based more on the irradiation protocol than on the macroscopic appearance of the skin.

[Role of plastic surgery in the conservative treatment of breast cancer]

Conservative surgery (CS) is widely accepted today as the treatment of choice for 60 to 80% of the primary breast cancer. Esthetic results of CS are not good in all the cases and improvement can be obtained thanks to the remodelling of the breast after tumorectomy. The scar should be selected according to the location of the tumor; the glandular tissue should be reshaped using local glandular flaps or following the principles of the reduction mammaplasties. Tumorectomy located in the upper part of the gland can be reshaped with an inferior pedicle type of mammoplasty. Defect located in the inferior part of the gland can be reconstructed with a superior pedicle mammoplasty. These sophisticated tumorectomies are providing good esthetic results on the reconstructed breast but require commonly a symmetry procedure on the contralateral breast. Such contralateral reduction allows a better exploration of the opposite breast and histological examination of the reduction specimen. In a series of 76 CS performed at the European Institute of Oncology (IEO), which were associated with some kind of plastic procedure to lower the risk of bad cosmetic results (representing 25% of the CS associated with plastic surgery), we confirmed the value of the mixed oncologic and plastic approach. The esthetic results observed in this series are better than those observed in another series previously published at the Gustave-Roussy Institute (IGR)--good results: 72% (IEO) vs 50% (IGR), and bad results: 6% (IEO) vs 20% (IGR). Statistically such comparison can be criticised, specially because of the short follow-up of the Milan series. However, the difference is rather important if we consider that the series of Milan was a selection of cases with poor esthetic expectation (25% of all the CS performed during the same period), while the series of Paris did not select the patients in what concerns the risk of poor esthetic result.

[Cutaneous suspension: immediate breast reconstruction with abdominal cutaneous advancement using a non-resorptive mesh. Preliminary results and report of 28 cases]

The immediate breast reconstruction with a definitive prosthesis (IBRDP) is the most useful technique in our experience. We proposed a technique to allow the use of IBRDP also in cases of mastectomy with large skin excision and also to permit a better definition of the inframammary fold. The prosthesis pocket is prepared as usually with the pectoralis major and serratus anterior muscles and then, a skin flap is undermined about 6-8 cm below the inframammary fold to prepare an upper abdominal skin flap. The innovation point is the use of a triangular non absorbable mersilene mesh to pull up and maintain the flap. The mesh is initially sutured at the future inframammary fold projection 4 to 6 cm lower than the previous inframammary fold and sutured under tension to the third and fourth costal cartilages. The prosthesis is located in front of the mesh and behind the muscles. Twenty nine patients had a mastectomy with IBRDP with the "Cskin suspension" technique at European Institute if Oncology (IEO) from june 1995 to september 1996. Only one case (3.4%) had a prosthesis loss 3 months after the surgery, probably by a prosthetic material rejection. This technique permits an IBRDF for the patients with a good abdominal skin laxity and also avoids the use of a more complicate or a more expensive technique (myocutaneous flaps or skin expanders). The small post-operative complications rate must be confirmed by a larger follow-up to evaluate the capsular contracture rates and the final cosmetic results.

[Mammoplasty for symmetry of the contralateral breast and its oncologic value]

Controlateral occult carcinomas are observed in 3 to 5% of the reduction mammaplasty of the controlateral breast at the time of the breast reconstruction. The symmetry procedure allows a good check up of the glandular tissue of the controlateral breast, especially when there is no evidence of tumor. The different techniques of breast reduction provide specific possibilities for such exploration and should be chosen according to the area which should be explored. The superior pedicle technique gives us the best exposure and an easier modelling. It gives a good aesthetic results in 80% of cases. The central pedicle and dermoglandular pedicle technique give a good exposure and permits us to fill the defect with glandular flap. The drawback of the inferior pedicle technique is the lack of control of the central and inferior quadrant.

[Reconstruction of the anterior chest wall by a sandwich-type combination of a synthetic support and a muscle flap from the latissimus dorsi. Apropos of a case]

Reconstruction of the chest wall after balistic or other trauma requires good and muscle cover and creation of a new, stable and airtight wall. The authors present a case of balistic trauma of the right anterolateral chest wall which was urgently debrided and subsequently reconstructed by sandwich combination of a latissimus dorsi muscle flap and synthetic material composed of a sheet of PTFE and creation of two methylmethylacrylate ribs. The advantage of this technique is that it avoids the use of autologous tissue from an already weakened chest wall and confers a new chest stability in several sites corresponding to the wall defect with easily available and easy-to-use materials.