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Resume But de l’etude La reconstruction mammaire par lambeau de grand dorsal et lipofilling est une technique tres utilisee en pratique courante. Certains operateurs lui reprochent neanmoins l’absence de resultat definitif lors de la premiere intervention, et la necessite de seances repetees de lipofilling. L’objectif de cette etude etait de comparer le nombre de reinterventions chez les patientes ayant beneficie d’une reconstruction par grand dorsal sans prothese versus avec prothese. Patients et methodes Nous avons inclus les patientes operees d’une reconstruction mammaire par lambeau de grand dorsal avec ou sans prothese entre 2008 et 2012 dans notre centre. Nous avons releve le nombre de nouvelles interventions chirurgicales chez ces patientes, qu’il s’agisse de lipofilling ou de reprise liee a l’implant. Nous avons egalement note le poids moyen de la mastectomie dans les deux groupes sur chaque annee. Resultats Cent quatre-vingt-six patientes ont ete incluses dans cette etude. Quatre-vingt-onze patientes ont beneficie d’une reconstruction par grand dorsal et prothese, et 95 patientes d’une reconstruction par grand dorsal et greffe adipocytaire. Il n’a pas ete mis en evidence de difference significative concernant le nombre d’interventions supplementaires entre les deux groupes. Le poids moyen des mastectomies dans le groupe autologue n’a cesse d’augmenter sur les cinq ans. Il n’existait pas de difference significative concernant le poids moyen des mastectomies entre les deux groupes sur les deux dernieres annees. Conclusion L’evolution des indications dans notre centre s’est faite vers l’absence d’implantation prothetique en cas de reconstruction mammaire par grand dorsal, quel que soit le volume du sein.

In March of 2010, French authorities suspended the use of breast implants made by the company Poly Implant Prothèse. Institut Curie is a large cancer center, and Poly Implant Prothèse was one major silicone-filled breast implant brand used. This report describes the impact of the fraudulent implants worldwide and more specifically on patient care at the authors' unit. From 2002 to 2009, the median number of Poly Implant Prothèse implants removed per year was 32. Since the first alert in March of 2010, 252 of these breast implants were removed in 2010 and 2011. The breast implants removed were mainly reported as normal, with a rupture rate of less than 5 percent before 2008. However, the annual rupture rate has increased from 2008 to 2011 (8, 14, 20, and 23 percent, respectively). The Institut Curie, in conjunction with breast cancer patients, has organized a management plan to deal with this major industrial fraud. Its surveillance program of breast cancer patients facilitated the management of patients during this difficult time.

Tumor hypoxia is a hallmark of malignant tumors, and is a major factor in the resistance to anti-cancer therapies, particularly radiotherapy. Indeed, tumor blood flow often fluctuates, and thus the oxygen supply is often reduced, thereby inducing tumor hypoxia. We decided to explore whether post-occlusive reactive hyperemia, a physiological reaction known to occur in normal tissues, could be induced through a malignant tumor, basal cell carcinoma (BCC), in which angiogenesis occurs, as in all malignant tumors. Skin blood flow was measured in twelve patients with BCC, using Laser Speckle Contrast Imaging to determine BCC perfusion after three minutes of vascular occlusion, induced by limb tourniquet for limb tumors (4 BCC), and/or by clamping the pedicle of a skin flap with the BCC at its center, for other tumor locations (12 BCC). We demonstrated for the first time that post-occlusive reactive hyperemia occurs in malignant tumors in humans. BCC perfusion curves were similar to those of healthy skin, characterized by a peak of hyperemia after reperfusion followed by a progressive return to the pre-occlusion perfusion level. Induction of post-occlusive reactive hyperemia in malignant tumors is therefore a novel investigational approach that could lead to a new adjuvant tool to increase the efficacy of chemotherapy and radiotherapy, respectively through the synchronized temporary increase of tumor perfusion and oxygenation.

Resume L’abdomen est un site donneur de choix en reconstruction mammaire. Depuis 30 ans, les techniques ont evolue en cherchant a diminuer la morbidite du prelevement tout en augmentant la fiabilite du lambeau. Le lambeau de superficial inferior epigastric artery (SIEA) permet d’epargner l’aponevrose abdominale et assure une reconstruction mammaire autologue de qualite. Le pedicule de ce lambeau et son angiosome presentent cependant une importante variabilite le rendant moins fiable que les autres lambeaux abdominaux. Materiel Le vert d’indocyanine est un colorant soluble qui, illumine par une source laser infrarouge, emet une lumiere fluorescente qui n’est pas piegee par la peau. Ces caracteristiques en font un excellent marqueur de la perfusion cutanee. Un meme dispositif (le Photo Dynamic Eye®) assure l’emission du rayonnement infrarouge et la reception de la fluorescence. Il permet ainsi de determiner pendant l’intervention l’angiosome du lambeau disseque. Protocole chirurgical Apres dissection des vaisseaux epigastriques inferieurs superficiels, le lambeau abdominal est leve de la paroi abdominale en preservant la perforante dominante issue des vaisseaux epigastriques inferieurs profonds. Apres clampage atraumatique de cette perforante, l’angiographie fluorescente peroperatoire au vert d’indocyanine est realisee et permet de caracteriser l’etendue de la palette cutanee vascularisee par le pedicule du SIEA. En fonction du resultat et de l’indication, le chirurgien choisit de realiser un SIEA ou un DIEP. Resultats Les auteurs presentent quatre cas cliniques de reconstructions mammaires par SIEA pour illustrer ce procede. Conclusion Le lambeau de SIEA est une technique operatoire supplementaire dans l’arsenal therapeutique en reconstruction mammaire par tissu autologue, en complement du DIEP. Il permet une reconstruction sans sacrifice aponevrotique ni dissection intramusculaire. La realisation d’une angiographie peroperatoire au vert d’indocyanine permet de caracteriser l’angiosome du lambeau et de fiabiliser son utilisation.

Resume En reconstruction mammaire, l’infection periprothetique est l’une des complications les plus redoutees. Sa prise en charge n’est pas clairement definie. L’attitude classique non conservatrice est generalement recommandee avec une nouvelle pose d’implant trois a six mois plus tard. Cette prise en charge fait perdre le benefice de la premiere intervention et peut compromettre le resultat final. Patientes et methode Les auteurs presentent une serie de sept sauvetages precoces d’implants consecutifs chez six patientes, sur une periode allant de fevrier 2008 a octobre 2009, pour un total de 304 reconstructions par protheses. Toutes les patientes ont ete operees selon le meme protocole : ablation de l’implant, lavage de la loge par 6 l de serum, remplacement de l’implant, antibiotherapie probabiliste anti-staphylocoque puis adaptee aux resultats bacteriologiques pendant trois semaines. Resultats Les sept infections ont ete traitees avec succes. Aucune recidive infectieuse n’est reportee avec un suivi moyen de 16 mois. Un cas de coque Baker III est retrouve. Les resultats ont ete juges comme moyen dans un cas et comme satisfaisant ou tres satisfaisant dans six cas. Conclusions En cas d’infection periprothetique et en l’absence sepsis severe ou de necrose cutanee, le sauvetage de la reconstruction par lavage abondant est une alternative efficace a l’ablation de l’implant.

Wound defects resulting from wide local excision for cutaneous melanoma, can require the use of skin graft for closure. Harvesting the skin graft can result in an additional morbidity. The increasing use of sentinel lymph node biopsy in cutaneous melanoma allows us the development of an alternative technique for obtaining donor skin. This method utilizes the skin overlying the sentinel lymph node as the skin graft donor site. Sixteen patients with cutaneous melanoma over than 1 mm of Breslow index, underwent wide local excision with sentinel lymph node biopsy and full thickness skin graft harvested from the node biopsy site. After a median follow-up of 18 months, there were no graft failure, one case of lymph swelling was relieved in the donor site. There were no melanoma recurrence and no metastasis. One case of in transit metastasis was treated by local excision and suture. In cases were primary closure is not feasible or cosmetically unfavourable, the use of the sentinel lymph node site as a skin graft donor, provides an alternative technique sparing the patient an additional skin graft donor site defect.

Breast reconstruction with latissimus dorsi flap and fat grafting is a technique widely used in current practice. Some operators still complain at the lack of final results at the first intervention and the need for repeated lipofilling sessions. The objective of this study was to compare the number of reoperations in patients who underwent reconstruction with latissimus dorsi with prosthesis versus without prosthesis.We included all patients operated for breast reconstruction with latissimus dorsi flap, with or without prosthesis between 2008 and 2012 in our center. We noted the number of new surgical interventions in these patients on the reconstructed breast. We also noted the average weight of mastectomy in two groups each year.One hundred and eighty-six patients were included in this study. Ninety-one patients underwent reconstruction with latissimus dorsi and prosthesis, and 95 patients reconstruction by latissimus dorsi and fat graft. It has not been demonstrated significant differences in the number of new surgical procedures between the two groups. The average weight of mastectomies in the autologous group has steadily increased over the five years. There was no significant difference in the average weight of mastectomies between the two groups over the last two years.For breast reconstruction with latissimus dorsi flap, surgical indications changed in our center to the absence of prosthetic implant, whatever the volume of the breast.

The lower abdominal skin and fat have become a standard for breast reconstruction. For 30 years, techniques have evolved, seeking to reduce the morbidity while increasing the reliability of the flap. The Superficial Inferior Epigastric flap Artery (SIEA) spares the abdominal fascia and provides a very satisfying autologous breast reconstruction. However, the pedicle of this flap and its angiosome exhibit a considerable variability, making its use less reliable than other abdominal flaps.The Indocyanine green (ICG) is soluble dye. When illuminated by an near-infrared light, the ICG emits fluorescence that is not trapped by the skin. A single device (Photo Dynamic Eye(®)) provides the emission of the near-infrared light and the reception of the fluorescence. It provides therefore a simple and efficient intraoperative real-time surface angiographic imaging. SURGICAL PROTOCOL: After dissecting the superficial inferior epigastric vessels, the abdominal flap was harvested from the abdominal wall preserving one perforator arising from the deep inferior epigastric vessels. The perforator was then clamped, and the vascular territory of the SEIA artery was visualized using laser-induced fluorescence of the indocyanine green. The surgical technique was modified depending on the indication for surgery and the result of perfusion measurements.The authors present four clinical cases of breast reconstruction with SIEA to illustrate this procedure.The SIEA flap is another surgical technique to achieve autologous breast reconstruction without abdominal morbidity or muscular dissection. Intraoperative angiographic imaging with ICG makes this flap more reliable.

In breast reconstruction, periprosthetic infection is one of the most feared complications. Treatment is not clearly defined. The classical recommendation mandates implant removal and antibiotic treatment before a 3- to 6-month delayed reimplantation. This approach may compromise the final result.The authors present a series of seven consecutive infected implants early "salvages" in six patients over 304 implants during a period ranging from February 2008 to October 2009, All patients were operated using the same protocol: implant removal, irrigation with 6l of saline, implant replacement, antibiotic treatment for staphylococcus during 3 weeks.The seven infections were treated successfully. No recurrent infection was found with a mean follow-up of 16 months. One case of Baker III capsular contracture is noticed. Cosmetic results were moderate in one case, and satisfying or very satisfying in six cases.In case of periprosthetic infection without sign of severity or skin necrosis, abundant irrigation and implant salvage is an effective alternative to implant removal.

Wound defects resulting from wide local excision for cutaneous melanoma, can require the use of skin graft for closure. Harvesting the skin graft can result in an additional morbidity. The increasing use of sentinel lymph node biopsy in cutaneous melanoma allows us the development of an alternative technique for obtaining donor skin. This method utilizes the skin overlying the sentinel lymph node as the skin graft donor site. Sixteen patients with cutaneous melanoma over than 1 mm of Breslow index, underwent wide local excision with sentinel lymph node biopsy and full thickness skin graft harvested from the node biopsy site. After a median follow-up of 18 months, there were no graft failure, one case of lymph swelling was relieved in the donor site. There were no melanoma recurrence and no metastasis. One case of in transit metastasis was treated by local excision and suture. In cases were primary closure is not feasible or cosmetically unfavourable, the use of the sentinel lymph node site as a skin graft donor, provides an alternative technique sparing the patient an additional skin graft donor site defect.