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Abstract: Tumefaction arising lately after latissimus dorsi flap harvest are rare and observed in 1 or 2% of the cases. These lesions are frequently related to kystic sero-hematoma and are easily and efficiently treated with surgical excision. In some rare circumstances, a tumoral evolution can mimic a kystic sero-hematoma. We will discuss one case of desmoid tumor arising from a latissimus dorsi flap donor-site scar. The subject was a 45 years old woman who had a breast reconstruction following mastectomy. A dorsal tumefaction, with a benign aspect, was observed during the follow-up period. The biopsy showed an extra-abdominal desmoid tumor. The patient was treated with a large excision of the lesion and reconstructed using two opposing local cutaneous advancing flaps. No radicalization was necessary. No sign of recurrence has been observed at 4 years follow-up. [Copyright &y& Elsevier]

Summary: Breast reconstructions are plastic surgeries that female patients, who have undergone mastectomies, are increasingly using. While the morphological results are appreciated by patients themselves as being more and more satisfactory, results in terms of sensitivity remain uncertain and depend on type of reconstruction used. The chest wall skin already desensitized by mastectomy and exposed to radiotherapy presents disturbance of blood supply and innervation, likely responsible for impaired local thermoregulation that can easily lead to thermal burn injuries. Our paper presents a rare ethiopathological burn entity on the reconstructed breast: the association between short sun exposure and wearing black clothes. This aetiology of burns must be known by patients and by plastic surgeons in order to prevent dramatic clinical situations leading up to the loss of the reconstruction. [Copyright &y& Elsevier]

Summary: The correct management, with the classic techniques, of the thoracic deformity in Poland''s syndrome is difficult, with often insatisfactory results. The current surgical treatment involves the use of prothetic material and/or different flaps with their own complications and scares. The experience of our team with fat grafting (we named lipomodeling) in breast reconstruction helped us to propose the correction of the thoracic and mammary deformity by repeated fat transfer sessions. Fat grafting is commonly used in our team since 1998 in various indication of breast surgery. We reviewed retrospectively our ten first cases of thoracic deformity in Poland''s syndrome treated with only fat grafting. Patients had repeated procedures until obtaining a satisfactory result. The fat was harvested from the thigh, buttocks, and abdomen. There were young patients with a mean age of 16years old (from 12 to 24). The mean follow-up was 51months. An average of 2.9 procedures (1 to 5) with 255cm3 of fat injection at each procedure was needed to obtain symetry. Hundred percent of the patients were satisfied. No complication was noted. As reported, the reconstruction of the thoracic deformity and the mammary shape can be obtained by fat grafting. The absence of a flap donor site sequelae and the absence an implant allow this technique to be simple, reproductible, and without great complication. These criteria match well the surgical management of this deformity, which is mainly aesthetic. Moreover, the secondary benefit of liposuction of disgracious steatomery helps the acceptance of the procedure. Therefore in our hands, fat grafting to the breast (lipomodeling) is now our first choice treatment in thoracic Poland syndrome deformity. Given the rarity of this syndrome, we recommend a treatment by an operator who makes the learning curve of lipomodeling, and who often deals with Poland syndrome. [Copyright &y& Elsevier]

Summary: The radiation treatment of malignant facial tumors in children may induce major functional and cosmetic sequelae, mainly due to uneven growth of the bones and soft tissues, resulting in facial asymmetry and hemihypotrophy at adult age. Although fat transfer has proven effective for facial cosmetic treatment, few studies have demonstrated the benefit of the technique in heavily irradiated tissues. The techniques generally used for the treatment of facial asymmetry or hypotrophy are ill-adapted to irradiated patients. Indeed, procedures such as skin detachment, osteotomy and vascular suture are risky because of radiation-induced damage. The aim of the present study was to investigate the potential benefits of fat transfer for the correction of sequelae of facial irradiation. Four patients (two males and two females) aged 27, 25, 16 and 13 years underwent fat grafting for the correction of facial asymmetry or hypotrophy induced by cancer radiation treatment during childhood (radiation dose of more than 50Gy). One to three grafting sessions were required, depending on the cases. After a median follow-up of 3.9 years, cosmetic results were considered satisfactory by both the patient and the surgeon in all four cases. Fat transfer remarkably improved the cosmetic appearance of the patients, without deleterious consequences for the vitality of tissues. In addition, a restoration of skin trophicity was observed, thus confirming the benefit of grafting adipocytes into the irradiated integument. In conclusion, fat grafting appears to be a simple and easily reusable technique which makes it possible to obtain the best morphological and cosmetic results in irradiated patients, whereas avoiding complex and potentially hazardous procedures. [Copyright &y& Elsevier]

Summary: 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 600cm3 (min: 266cm3, max: 926cm3). 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. [Copyright &y& Elsevier]

Summary: Breast lipomodelling has been used in our unit since 2002 to correct the sequelae of conservative treatment of cancer. Morphologically, satisfactory results have been recorded and the method is likely to develop considerably. However, the technique has also been questioned because of the possible deleterious radiological impact of injecting fat into the breast. The present work investigated the radiological aspect of conserved breast reconstructed by lipomodelling in a series of 21 patients undergoing ultrasound examination, mammography and MRI, before and after the procedure. Benign-looking microcalcifications were detected on 19% of the mammographies, small (<1cm) oily cysts and complex cysts were visible on respectively 57 and 19% of ultrasound images, whereas 47% of the MRI scans indicated cytosteatonecrotic lesions. Even though multiple events could be observed, their frequency is close to that observed following other conventional breast surgery. Besides, there is clear radiological evidence of benignity. The conclusion of the study is that images obtained after lipomodelling are satisfactory and in no way suggestive of recurrence of breast cancer. Provided that radiologists and experts are aware of this pattern, there is no impact on the radiological follow-up of the patients. [Copyright &y& Elsevier]

Summary: Thanks to the earlier detection of breast cancer, the advent of neoadjuvant therapy and the development of more effective surgical procedures reducing treatment sequelae, conservative treatment has dramatically expanded over the past 15 years. Several factors have recognized negative aesthetic consequences for breast cancer patients: being overweight, having voluminous or on the contrary, very small breasts, having a tumor located in the lower quadrant, having high breast-tumor: breast-volume ratio. Tissue injuries induced by radiotherapy and chemotherapy, such as shrinking, fibrosis or induration, maximize the deleterious impact of surgery. The results of conservative treatment also deteriorate with time: weight gain is common and may result in increased breast asymmetry. Patients undergoing conservative treatment may experience sequelae including various degrees of the following dimorphisms, all possibly responsible for minor or even major breast deformity: breast asymmetry, loss of the nipple/areola complex, scar shrinkage and skin impairment, irregular shape and position of the nipple and areola. Various sensory symptoms have also been reported following conservative treatment, with patients complaining of hypo- or dysesthesia or even suffering actual pain. Breast lymphedema is also a common incapacitating after-effect that is believed to be largely underdiagnosed in clinical practice. Finally, like mastectomy, conservative breast surgery may induce serious psychological distress in patients who suffer the loss of physical integrity, womanhood or sexual arousal. Clinicians must be aware of the radiological changes indicative of late cancer recurrence. There are four types of modifications as follows: increased breast density, architectural distortion at the surgical site and formation of scar, mammary fat necrosis, and occurrence of microcalcifications. The management of sequelae of conservative breast treatment must therefore involve a multidisciplinary approach; patients not only expect better cosmetic appearance, but also a focus on other treatment advances such as improvement of psychological and sensory outcome. The interpretation of radiological images is also an integral part of the management of these patients at significant risk of recurrence. [Copyright &y& Elsevier]

Summary: Skin-sparing mastectomy (SSM) has emerged as the surgical technique best adapted to the treatment of early breast cancers or breast cancer recurrences after conservative treatment; the technique is particularly appreciated by the patients who had been expecting the development of immediate, high-quality breast reconstruction for over 15 years. SSM preserves anatomical landmarks on the skin surface (notably the under-breast fold and the conical shape of the breast). The procedure must be performed by a skilled surgical team in order to maximize the quality of breast resection and reconstruction, particularly to avoid postoperative complications, notably damage to blood vessels within the skin flap and prosthesis infection. These complications generally affect the cosmetic outcome of the reconstruction, with serious short-term and long-term consequences for the acceptability of the surgical procedure, and may sometimes compromise the delivery of adjuvant treatments (either chemo- or radiotherapy). Based on our previous experience (1000 new cases since 1992), we will compare the advantages and drawbacks of the procedure, discuss its indications, describe the clinical situations encountered and the various specific interventions available, as well as the methods to reduce the risks of tissue damage and skin necrosis. [Copyright &y& Elsevier]

Summary: 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. [Copyright &y& Elsevier]

Summary: In our unit, breast cancer patients suffering mild sequelae of conservative cancer treatment receive fat transfer (lipomodelling), following a precise protocol, based on mammographic and ultrasound examinations and MRI. Available data do not seem to indicate any deleterious impact on patient outcome, notably in view of radiological images, but recurrence (or rather occurrence of new ipsilateral or contralateral cancer) is frequent. The correlation between new or recurrent breast cancer and lipomodelling is high; misinterpretations are possible and frequently arise. The present paper is a description of five complex clinical cases and a discussion of the medicolegal issues that may possibly arise; it also provides tentative expert evaluation of the cases. Clinical findings are reported and analyzed. The second step is a discussion of the radiological impact of lipomodelling, and of the problems caused by the transfer of potentially malignant cells when no preoperative diagnosis of recurrence is made; the morphological and esthetic benefits of the method are described, as well as the potential beneficial impact of fat transfer, notably associated with lower breast density and injections of fat stem cells. Our conclusion is that specialized radiologists, as well as plastic surgery and oncology experts should address the question of fat transfer in operated breast cancer patients and give their reasoned opinion about potentially litigious cases. This would help minimize or solve the conflicts between patients, doctors and experts. Establishing common ground between the different stakeholders would allow the development of the technique, as lipomodelling is, according to our experience, a tremendous advance in the treatment of sequelae from conservative breast cancer surgery. [Copyright &y& Elsevier]

Abstract: First described by Texier in 1994, the mediodorsal transposition flap of the nose is an island flap. The paramedian dorsal arteries (anastomosed to the interdomal plexus) ensured the axial vascularisation in SMAS plane. The authors will discuss their personal approach to the surgical procedure for the improvement of final result, with four clinical cases. This flap can be used for aesthetic unit reconstruction of cutaneous or mucosal different alar defect (partial or complete, full-thickness or not). This reliable flap represents an alternative technique of composed grafts, of different nasolabial flaps, and of forehead flap. [Copyright &y& Elsevier]

Summary: Introduction: Pyoderma gangrenosum (PG) is a rare chronic inflammatory skin disease characterized by the recurring development of necrotizing and painful ulcers and therefore, often misinterpreted. This condition can simulate fulminant infection, particularly after surgery. The presentation is often impressive in extensive ulcerations and scarring and lead to significant sequelae. A rapid initial management avoids a dramatic evolution. Patients and methods: We report the case of three PG for patients followed for breast reconstruction after breast cancer. Discussion: PG is a neutrophilic dermatosis that can occur after injuries of varying intensity. Its shape after surgery is a rare disease whose presentation loud and fast pace “infectious” contrasts with the absence of inflammatory lymphangitis or lymphadenopathy. Be aware of prescribing high doses of corticosteroids. Conclusion: These three cases illustrate the importance for early diagnosis and treatment of PG, who can allow spontaneous healing without complex surgery, always feared in this context. [ABSTRACT FROM AUTHOR]

Summary: Introduction: Cutaneous radionecrosis and osteoradionecrosis are severe complications of the radiotherapy which can arise after a variable free interval. The loss of substance is frequently associated with a peripheral radiodermatitis and stays an infectious front door exposing patients to a sepsis. The reference treatment remains surgical and consists in realizing the debridment of necrosis tissues associated with flap in order to cover the soft tissus defect. The purpose of our study is to estimate efficiency and tolerance of management radionecrosis thoracique by muscle-sparing latissimus dorsi flap (MSLD). Material and methods: We realized a study on a series of cases of thoracic radionecrosis with costal exposure covered by MSLD. Fat transfer into peripheral radiodermitis was performed at the same time surgical. Efficiency and tolerance surgery were estimated. The duration of the postoperative antibiotic treatment was estimated. The complications (hematoma, infection, cutaneous suffering, necrosis, seroma, radionecrosis relapse) were screened. The follow-up was realized by the same surgeon. Results: Seven patients managed by the same surgeon were included, They had radionecrosis after radiotherapy for processing adjuvanting of mastectomy after breast cancer. The average age was 66 years (from 61 to 76 years). The average time of hospitalisation was of four days. The average follow-up was of six months. The average treatment of the antibiotic treatment was four weeks. We didn’t notice any complications and any recurrence of the radionecrosis. We noticed one dorsal collection (30 cm3) 15 days after surgical procedure for one patient. The follow-up showed a stable and good quality cutaneous cover in six months postoperative. Conclusions: MSLD flap is reliable and reproducible to cover moderate thoracic defect. The surgical parage-wash has a fundamental importance to avoid any infectious complication. The management of the thoracic radionecrosis is complex and multidisciplinary. In conclusion, MSLD flap seems to be an elegant surgical alternative insuring a custom-made optimal cover with a reduction of the morbidity of the site donor. [Copyright &y& Elsevier]

Summary: 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. [Copyright &y& Elsevier]

Summary: Lateral breast defect after partial mastectomy is a difficult challenge. Pedicled perforator flap is a new indication for breast surgery. Perforator flaps and fat tissue transplant are new concepts in this kind of reconstruction. Lateral intercostal artery perforator (LICAP) flap has been used for a lot of indications. It can be used for lateral breast defect reconstruction. This flap provides several advantages: minimal donor site morbidity, advantages in flap shaping, better aesthetic results and higher patient satisfaction. The aim of this paper is to present indications of LICAP flap. We discuss its advantages and its limits in lateral breast reconstruction after partial mastectomy. LICAP flap provides a new solution instead of conventional flaps. [Copyright &y& Elsevier]

Summary: Introduction: Breast rupture is an uncommon event that has become more frequent from the 1980s, with the generalisation of the seat belt, so that we can now speak of seat belt related injuries. The trauma is often forgotten and leaves a fibrous band in the breast as only mark. In this way, the breast can be deformed by the scar as much as the retraction is important. The clinical presentation can mime that of a breast cancer, so it is really important to do an echography and a mammography of the lesion. If some dilemma remains, IRM or core biopsy can be helpful. Patients and methods: We report two cases of breast rupture. A breast cancer has been excluded with echography and mammography. We performed a reduction mammoplasty, with inverted T scars, conserving a posterior glandular flap. We will present the observations in the article. Discussion: A breast trauma often leads to haematomas, necrosis of fat and lipid cyst formation. Typically, these lesions are located in regard to the passage of the seat belt on the thorax. The surgical treatment should correct an oblique deformation. It is important to excise all the fibrous tissue and to reharmonize the glandular content. Moreover, in the accidentally discovered forms, one should take in mind the vascular damage determined by the lesions and be able to recognise its presentation before the operation. Conclusions: Breast rupture is a rare situation that should be known. The treatment is simple and consists in excising the fibrous tissue and replacing it with a well-vascularised tissue. The posterior glandular flap is a helpful tool in these situations. [ABSTRACT FROM AUTHOR]

Summary: Seroma is the most frequent minor complication after harvesting latissimus dorsi flap for breast reconstruction. It induces patient''s discomfort and multiple consultations for punctions. The dead space resulting from the harvest has to be closed by the “quilting suture” in order to prevent the seroma. Our aim is to evaluate the efficiency and the tolerance of the quilting suture by comparing two groups of 100 patients who had a breast reconstruction by the same technic of extended latissimus dorsi flap, performed by the same surgeon, from 2004 to 2007. Half of patients had the classic way of dorsal closure, and the other half of patients had the dorsal quilting suture. Patients and methods: In order to compare the two groups we have collected data concerning age, body mass index (BMI), tobacco use, postoperative complications, number and volume of punctions, draining time and postoperative pain. The efficiency of the quilting suture lies on a rigorous repartition of at least six sutures on the upper skin flap, 12 on the lower skin flap and under the skin suture line. The suture model is based on the one used for the Chippendale-designed sofa. We suture the skin flap while pushing down the shoulder, in order to split the skin tension and avoid traction on the final skin suture line. The procedure takes 15minutes. Results: The “Chippendale” technic allows to reduce draining time from 12 days to 6 days. The incidence of chronic seroma is reduced by 50%. The dorsal wound healing seems also better thanks to tension reduction resulting from the quilting suture. Conclusion: The “Chippendale” technic is a quick, cheap and easy learned procedure, efficient for preventing chronic seroma after the latissimus dorsi flap. The postoperative recovery is eased and the patients comforted. [Copyright &y& Elsevier]

Background: Thorough training is essential to the success of colorectal laparoscopic surgery (LPS). The aim of this study was to evaluate the results of a 3-month training period in LPS. Methods: Before beginning the study, the surgical team attended several courses of LPS and spent a long time working at a large animal facility to perfect laparoscopic techniques. Twenty-six consecutive patients underwent LPS in a 3-month training period. Controls (n = 26) who underwent open colorectal surgery (LPT) were selected to match the LPS patients for age, gender, primary disease, type of surgery, comorbidity, and nutritional status. Results: Conversion to open surgery was necessary in one patient (3.8%). The operative time was 1 h longer for LPS than LPT (p < 0.001). The mean number of lymph nodes harvested was 17 in LPS and 18 in LPT (p = 0.76). The first flatus (p < 0.02) and bowel movement (p < 0.002) occurred earlier in the LPS group. The postoperative infection rate was 11.5% for LPS and 19.2% for LPT (p = 0.33). Two anastomotic leaks occurred in each group. The mean postoperative hospital stay was 9.6 days (standard deviation [SD], 2.6) for LPS and 11.0 days (SD, 5.2) for LPT (p = 0.68). Recovery of postoperative physical performance and social life occurred earlier in the LPS than the LPT group (p < 0.001). At 1-year follow-up, no difference was found in terms of cancer recurrence or long-term complications. Conclusion: Oncologic results and postoperative morbidity were comparable for LPS and LPT. LPS allows a faster postoperative recovery. [ABSTRACT FROM AUTHOR]