[Secondary surgery of breast reconstructions by breast implant. Assessment of patient satisfaction based on surgical technique implant conservation vs. autologous conversion]

INTRODUCTION

Breast reconstruction with implants has long-term disadvantages and is leading an increasing number of patients to request secondary corrective surgery. Two surgical strategies are possible: implant replacement (associated with capsulectomy/capsulotomy and/or lipofilling procedures) and implant removal associated with the provision of autologous tissue (flap and/or lipofilling).

METHOD

Between 2010 and 2018, 54 patients underwent secondary surgery for correction of a first implant breast reconstruction. The reasons for dissatisfaction with the initial reconstruction, the procedures performed, and postoperative complications were analysed. Patient well-being and satisfaction were evaluated using the BREAST-Q questionnaire.

RESULTS

Thirty-four patients benefited from a prosthesis change and 20 patients benefited from a permanent removal of their prosthesis combined with the addition of autologous tissue. The presence of a periprosthetic shell, pain, fixed appearance of the breast and breast asymmetry were the most frequent reasons for dissatisfaction. With a mean follow-up of 2.6 years, autologous conversion patients were generally more satisfied with the appearance of their breasts than patients who retained a breast implant (P<0.0001).

CONCLUSION

In cases of poor esthetic or functional outcomes of implant-based breast reconstruction, removal of the prosthesis in combination with autologous reconstruction provides better results in terms of well-being and satisfaction than implant replacement.

[Autologous breast reconstruction by deep inferior epigastric free flap: Classic and minimally invasive extraperitoneal approaches]

Perforator free flaps allow breast reconstructions « like with like » with skin and fat, excluding mammary gland, with a low morbidity. Those autologous reconstructions prevent material associated infections, capsular contracture and implant replacements, associated to breast reconstructions including implants. DIEP flap was described in 1994 to reduce the morbidity faced with TRAM flaps harvest. It only includes sub-umbilical skin and deep epigastric vessels. Deep inferior epigastric vessels harvest requires rectus abdominis muscle sheet opening and traction on rectus muscles, both associated with increased risks of abdominal bulges. Since 2014, we developed a minimally invasive DIEP harvest by totally extra-peritoneal laparoscopic dissection of epigastric vessels with a 70% reduction of aponeurosis opening and avoiding traction on rectus' motor nerves. We report both classic and minimally invasive DIEP harvest techniques. Bresat reconstructions by DIEP require that the ombilicus can be transposed and are indicated for all patients with need for skin inset, particularly secondary breast reconstructions. The reconstructed breast as a volume that follows patients weight variations and allows for improved quality of life on a long term. Its minimally invasive totally extra peritoneal harvest by laparoscopy, with or without robotic assistance, offers a reduced morbidity and might allows for reduced risks of abdominal wall weakness on a long-term.

[Should we drain after pre-pectoral breast implants? Analysis of a cohort of 400 patients operated for breast augmentation with pre-pectoral silicone implants]

AIM OF THE STUDY

During breast augmentation, surgical drainage remains a source of debate. The objective of the study was to determine the interest of the drainage after pre-pectoral breast implants pre, analyzing the risk of hematoma and capsular contracture.

PATIENTS AND METHODS

We retrospectively analyzed a cohort of 400 patients who underwent a first aesthetic breast augmentation by pre-pectoral silicone gel implants. Patients were followed with a maximum of nine years and a minimum of one year.

RESULTS

The mean age of patients was 37 years (18-64). Ninety-two percent (368 cases) had no drainage (patients "low risk of bleeding") and 8% (32 cases) underwent a bilateral drainage (patients "high risk of bleeding"). We recorded 1.75% hematoma (7 cases) and 2% of capsular contracture (8 cases).

CONCLUSION

We believe that the drainage should not be systematic for pre-pectoral breast implants. In patients at high risk of bleeding that we drained, it does not prevent the occurrence of a possible hematoma. In patients at low risk of bleeding that we have not drained, we do not observed more hematoma or capsular contracture than data published for drained patients.

[Two cases of lymphoma in an implant capsule: A difficult diagnosis, an unknown pathology]

The anaplastic large cell lymphoma (ALCL) is a rare disease, its incidence in the United States is one case per 500,000 women and three for 100 million patients for breast single location. Forty-six cases have been reported in the literature. They can grow on any type of implant: expander prosthesis silicone and saline, smooth or textured envelope. Currently, the consensus process includes capsulectomy, removal of the implant, chemotherapy and radiotherapy. However, some authors classify under indolent disease, but we believe that some cases may escape any therapeutic and become very aggressive forms. It is therefore important to make an early diagnosis and start treatment urgently. Severity and suspicion of iatrogenic nature of ALCL have an obligation to inform future with implants.