Traitement chirurgical des séquelles de brûlures profondes du sein : 25ans d’expérience

A National Review of Insurance Coverage of Noncancerous Breast Reconstruction

BACKGROUND

Breast reconstruction is commonly performed for a multitude of noncancerous indications, such as correction of congenital deformities, acquired tissue disease, burns, and trauma. However, breast reconstruction for noncancerous indications is often considered cosmetic or not explicitly mentioned in insurance policies. The goal of this study was to assess variability in insurance coverage of breast reconstruction for noncancerous indications.

METHODS

The authors conducted a cross-sectional analysis of 102 US insurance companies, including Medicare and Medicaid, for coverage of breast reconstruction for noncancerous indications (Poland syndrome, fibrocystic breast disease, burns and trauma). Insurance companies were selected based on their state enrollment data and market share. A Web-based search and individual telephone interviews were conducted to identify the policy. Medical necessity criteria were abstracted from publicly available policies.

RESULTS

Half of the insurers (49%, n = 50) had no policy for Poland syndrome, 46% (n = 47) had no policy for burns and trauma, and 82% (n = 84) had no policy for fibrocystic breast disease. Fifty-two percent (n = 22) of policies providing coverage for Poland syndrome, 24% (n = 13) of policies providing coverage for burns and trauma, and 58% (n = 7) of policies providing coverage for fibrocystic breast disease had specific, stringent criteria for medical necessity. Thirty-six percent (n = 15) of policies covering Poland syndrome, 47% (n = 26) of policies covering burns and trauma, and 33% (n = 4) of policies covering fibrocystic breast disease include coverage of the contralateral breast.

CONCLUSIONS

There is a paucity of publicly available information on insurance coverage of breast reconstruction for noncancerous indications and a lack of consensus between top US insurance companies on what constitutes medical necessity for surgical correction.

[Secondary surgical and medical treatment of scars]

The authors, through their experience, take stock of current secondary management of scars whether they are pathological (hypertrophic, cheloid) or dystrophic (enlarged, hypo- or hyper-pigmented, adherent) by presenting surgical or medical solutions.

[The breast of the adolescent girl]

During adolescence, psychological and physical changes occur and breast takes a major place in the young woman body image. Except rare malign tumors, breast pathologies at this age are mainly benign or malformative. Malformative issues are revealed during breast growth, as isolated asymmetry or associated to other regional anomalies, with abnormal shape or volume of the breast, or even supernumerary breast. Therapeutic solutions will not differ from the ones used for adults. Breast lipofilling, recently admitted by plastic surgery community is an interesting tool that can be used on young women. Choosing the right technic depends on the initial problem. It comes at an early stage to offset hypoplasia resulting in a problem of asymmetry. It waits for breast stability in case of hypertrophy and for legal majority in case of breast augmentation using implants. Psychological impairment stays however a central issue and forces the surgeon to adapt to the individual and to his body change over time.

Lipofilling, an efficient solution for breast sequelae after cardiothoracic surgery

Evolutions in pediatric cardiovascular surgery have allowed the treatment of a various range of cardiovascular malformations in infants. It is a difficult branch of surgery, with vital impact, which can also leave residual thoracic scars, possible sources for thoracomammary deformities in adults. Most thoracomammary deformities after thoracotomy are observed at puberty, when they appear as breast asymmetries. The main cause is the breast bud injured during thoracotomy. Several techniques have been suggested for breast reconstruction, but none give satisfying results. We have been practicing lipofilling since 1998 for breast reconstruction. Since 2001, we have started applying it to breast deformities. The final result is constant in time, natural, and has a good volume filler effect. We describe the fat grafting technique, an original technique, as a solution for this kind of deformities. The technique is illustrated by two clinical cases. In conclusion, fat grafting has really improved breast asymmetry due to iatrogenic deformation. Even if those cases are rare, surgeons have to know this kind of procedure. It is indeed a simple and efficient solution for those patients after childhood, with natural and long standing results.

Breast lipofilling: A new treatment of Becker nevus syndrome

INTRODUCTION

The association of Becker's nevus with other cutaneous, musculoskeletal or maxillofacial anomalies is called Becker nevus syndrome. Ipsilateral breast hypoplasia is the main reason for female patients to seek medical advice. We present two clinical cases of Becker nevus syndrome with thoracic nevus and ipsilateral breast hypoplasia treated with lipofilling alone (fat grafting).

MATERIAL AND METHODS

For the two consecutive cases of Becker nevus syndrome treated by fat grafts, we present the surgical technique and the outcome at one year follow-up. Fat was harvested with cannula after infiltration. The adipose tissue was prepared with a short centrifugation. Fat grafting was realized as backward injections.

RESULTS

We have noticed a concomitant improvement of the thoracic nevus color with a stable result after one-year follow-up. The aesthetic result after lipofilling was evaluated as very satisfying by the patient. The breast symmetry was improved.

CONCLUSIONS

We believe that the lipofilling technique is a natural and valuable treatment option for thoracic anomalies in Becker nevus syndrome with a major impact on patient's quality of life.

Percutaneous fasciotomies and fat grafting: indications for breast surgery

BACKGROUND

The management of breast deformities can be very difficult in the presence of breast shape retraction. Percutaneous fasciotomies, which release fibrous strings, can be a very useful tool for shape improvement in the recipient site for a fat graft.

OBJECTIVES

The authors evaluate the efficacy of fasciotomies in association with fat grafting in breast surgery.

METHODS

A retrospective chart review was conducted for 1000 patients treated with concurrent fasciotomies and fat grafting between January 2006 and December 2011. The recipient site was prepared with fasciotomies, and fat was harvested from other parts of the body using a low-pressure 10-mL syringe lipoaspiration system. Fat was centrifuged and injected into the breast for reconstruction or chest deformities. The postoperative appearance of the breast scars was scored by both the surgeon and the patient. Each complication was recorded, including instances of hematoma, infection, tissue wounds, scar healing, and fat necrosis.

RESULTS

In this series of patients, for whom the primary indications for the procedure were sequelae of breast-conserving surgery after cancer, latissimus dorsi flap breast reconstruction, breast implant reconstruction, tuberous breast, Poland syndrome, and funnel chest, we recorded the following complications: 0.8% local infections (8/1000), 0.1% delayed wound healing that required medical care (1/1000), and 3% fat necrosis (31/1000). Fasciotomy scarring was considered minor by the patient in 98.5% of cases and by the surgeon in 99% of cases at 1 year postoperatively.

CONCLUSIONS

Fat grafting is a safe and reliable technique that improves the aesthetic outcomes of breast surgery. Percutaneous fasciotomies provide excellent aesthetic results and an improvement in breast shape with no scarring. In our experience, both fat grafting and fasciotomies offer a durable result over the long term.

Breast amputation correction of a horse bite using the lipomodeling technique

Mammary gland development is an important phase of puberty, and it marks the passage into adulthood for women, so any trauma leading to mammary deformities has an important physical and psychological impact. Often, classic techniques are difficult to use in the treatment of traumatic breast lesions. In this article, the authors present an exceptional case of breast reshaping by lipomodeling in a teenage patient who had experienced a horse bite. Treatment included 2 fat grafting sessions with fasciotomies, nipple reconstruction using a bifoliated flap, and areolar tattooing, all without any complications. We achieved a satisfactory result with a symmetric volume, a natural tissue consistency, and sensation improvement, all of which were maintained as the patient grew. In our experience, fat transfer was a safe and reliable technique that provided a good and stable aesthetic result, improving the volume and shape without additional scarring or implant devices.

LEVEL OF EVIDENCE

5.

[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.