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Verga M, Kessels RL, Bonasegale A, Del Re L, Fenaroli P, Carminati M. 3D Lipogluing: Preliminary Results of a Novel Technique for Direct Three-dimensional Fat Grafting in Breast Reconstruction Surgery. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2024; 12:e5788. [PMID: 38712016 PMCID: PMC11073776 DOI: 10.1097/gox.0000000000005788] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2024] [Accepted: 03/18/2024] [Indexed: 05/08/2024]
Abstract
Lipofilling has emerged as an effective technique in breast reconstruction for enhancing aesthetic outcomes and addressing residual deformities. Traditionally, fat grafting has been performed as a secondary step in implant-based breast reconstruction during the replacement of the expander with a breast implant or as a revisional procedure. Our study investigates the technical feasibility and presents preliminary results of a new promising technique for delivering fat grafting in a three-dimensional (3D) shape, directly during mastectomy with immediate breast reconstruction or in delayed breast reconstructive procedures. Our new 3D lipogluing technique involves securing the fat tissue in a 3D manner using fibrin glue. This method enhances the coverage of soft tissues and provides improved volume and shape supplementation. In selected cases between December 2015 and September 2023, we treated 24 patients using the 3D lipogluing technique and five patients using 3D lipocubing (without use of fibrin glue).The patient cohort consisted of different indications for breast reconstructions: direct-to-implant, expander-based breast reconstruction, and "conservative" surgery. Preliminary findings suggest the technique is a safe and effective approach that can enhance the soft-tissue envelope of reconstructed breasts by acting as an autologous scaffold, owing to its regenerative properties. This technique not only improves the overall aesthetic outcome but also has the potential to reduce implant-related complications. Furthermore, ongoing studies are investigating methods to optimize the results and explore the potential application of 3D lipogluing and 3D lipocubing in breast-conserving oncoplastic surgery, cosmetic breast surgery, and other areas of plastic reconstructive and aesthetic surgery.
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Affiliation(s)
- Maurizio Verga
- From the Division of Plastic Surgery, Papa Giovanni XXIII Hospital, Bergamo Italy
| | - Raquel Leão Kessels
- Faculty of Health, Medicine & Life Sciences, Maastricht University, Paesi Bassi
| | - Anna Bonasegale
- Division of General Surgery, “Ospedale Civile di Vigevano” Hospital, Pavia, Italy
| | - Luca Del Re
- Division of General Surgery, “Ospedale Civile di Vigevano” Hospital, Pavia, Italy
| | - Privato Fenaroli
- Division of Breast Surgery, “Papa Giovanni XXIII” Hospital, Bergamo Italy
| | - Marcello Carminati
- From the Division of Plastic Surgery, Papa Giovanni XXIII Hospital, Bergamo Italy
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Stein MJ, Applebaum SA, Harrast JJ, Lipa JE, Matarasso A, Gosain AK. Practice Patterns in Primary Breast Augmentation: A 16-Year Review of Continuous Certification Tracer Data from the American Board of Plastic Surgery. Plast Reconstr Surg 2023; 152:1011e-1021e. [PMID: 37014959 DOI: 10.1097/prs.0000000000010497] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/06/2023]
Abstract
BACKGROUND As part of the continuous certification process, the American Board of Plastic Surgery collects case data for specific tracer procedures in aesthetic surgery to assess practice improvement by the diplomates. These case-based data provide valuable information on national trends in clinical practice. The current study was performed to analyze practice patterns in aesthetic primary breast augmentation. METHODS Breast augmentation tracer data were reviewed from 2005 to 2021 and grouped into an early cohort (EC), from 2005 through 2014, and a recent cohort (RC), from 2015 through 2021. Fisher exact tests and two-sample t tests compared demographic characteristics of the patients, surgical techniques, and complication rates. RESULTS Patients in the RC were slightly older (34 versus 35 years; P < 0.001), more likely to have ptosis greater than 22 cm (20% versus 23%; P < 0.0001), less likely to smoke (12% versus 8%; P < 0.0001), and less likely to undergo a preoperative mammogram (29% versus 24%; P < 0.0001). From a technical standpoint, inframammary incisions have become more common (68% versus 80%; P < 0.0001), whereas periareolar incision use has decreased (24% versus 14%; P < 0.0001). Submuscular plane placement has increased (22% versus 56%; P < 0.0001), while subglandular placement has decreased (19% versus 7%; P < 0.0001). Silicone implants are most popular (58% versus 82%; P < 0.0001). Textured implant use increased from 2011 (2%) to 2016 (16%), followed by a sharp decline to 0% by 2021. Trends follow U.S. Food and Drug Administration approvals and warnings. CONCLUSIONS This study highlights evolving trends in aesthetic breast augmentation over the past 16 years. The most common technique remains a smooth silicone prosthesis placed in the subpectoral plane through an inframammary incision.
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Affiliation(s)
- Michael J Stein
- From the Department of Plastic and Reconstructive Surgery, Lenox Hill Hospital
| | - Sarah A Applebaum
- Division of Plastic Surgery, Ann and Robert H. Lurie Children's Hospital
| | | | - Joan E Lipa
- American Board of Plastic Surgery, Inc
- Division of Plastic, Reconstructive, and Aesthetic Surgery, University of Toronto
| | - Alan Matarasso
- From the Department of Plastic and Reconstructive Surgery, Lenox Hill Hospital
| | - Arun K Gosain
- Division of Plastic Surgery, Ann and Robert H. Lurie Children's Hospital
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Jabir S, Vadodaria S, Nugent N, Sankar TK. Breast Augmentation: A Cross-Sectional Survey of UK and Irish Aesthetic Surgeons. Aesthet Surg J Open Forum 2023; 5:ojad070. [PMID: 37564462 PMCID: PMC10411920 DOI: 10.1093/asjof/ojad070] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/12/2023] Open
Abstract
Background Breast augmentation surgery is the most frequently performed aesthetic surgical procedure within the United Kingdom year on year. However, many variations exist among surgeons regarding various aspects of implant usage and technique. Objectives The aim of this study was to evaluate current trends and practices in breast augmentation, within the United Kingdom and correlate them to evidence-based literature. Methods An electronic survey of 41 questions was sent to 201 surgeons performing breast augmentation within the United Kingdom and Republic of Ireland. The survey inquired about the surgeons themselves, their practice, implant choice, surgical technique, post-op care, revision surgery, and impact of breast implant-associated anaplastic large cell lymphoma among several other questions. Results There were a total of 166 respondents, with 146 completing the survey fully, equaling a response rate of approximately 73%. Overall, there were specific trends in certain aspects such as type of practice, number of augmentations performed per surgeon per year, preferred implant manufacturer, and implant characteristics. That said, there has been a change in other aspects such as implant texture with an increase in the use of smooth implants. The United Kingdom and Ireland concur with certain internationally dominant practice preferences, including the use of inframammary incisions and post-op bra use. Conclusions This survey suggests that many aspects of breast augmentation surgery in the United Kingdom are approaching standardization. There are, however, some variations in practice and controversies remaining as expected. It is our belief that further standardizing this very common aesthetic surgical procedure according to evidence-based guidelines will help to improve outcomes for patients.
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Affiliation(s)
- Shehab Jabir
- Corresponding Author: Mr Shehab Jabir, 20 Canterbury Way, Stevenage SG1 4DG, UK. E-mail:
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Lee J, Kim SH, Lee JH, Han BK. Understanding Silicone Breast Implant-Associated Complications for Radiologists. JOURNAL OF THE KOREAN SOCIETY OF RADIOLOGY 2021; 82:49-65. [PMID: 36237459 PMCID: PMC9432405 DOI: 10.3348/jksr.2020.0208] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/19/2020] [Revised: 01/15/2021] [Accepted: 01/19/2021] [Indexed: 11/15/2022]
Abstract
미용적 성형 및 유방암 수술 후 재건의 목적으로 사용되는 실리콘 보형물의 사용이 국내외에서 크게 증가함에 따라 진료 영역에서 실리콘 보형물 삽입술을 받은 환자들을 어렵지 않게 접하게 되었다. 기존에 알려져 있던 보형물의 파열이나 구축과 같은 합병증 외에 최근에는 유방 보형물 연관 역형성 대세포 림프종과 같은 악성 종양과의 연관성도 보고되면서 보형물 관련한 영상 검사가 증가하고 있다. 이러한 상황에서 영상의학과 의사들은 보형물 삽입술을 받은 환자에 대해 어떤 검사가 필요하고 어떤 영상 소견이 보형물 관련 합병증을 시사하는지에 관한 충분한 지식을 갖추고 있어야 할 것이다. 본 종설에서는 영상의학과 의사들이 알아야 하는 실리콘 보형물의 다양한 합병증과 이들의 영상 소견에 대해 다루고자 한다.
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Affiliation(s)
- Jeongmin Lee
- Department of Radiology, Seoul St. Mary's Hospital, The Catholic University of Korea, Seoul, Korea
| | - Sung Hun Kim
- Department of Radiology, Seoul St. Mary's Hospital, The Catholic University of Korea, Seoul, Korea
| | - Jae Hee Lee
- Human Medical Imaging & Intervention Center, Seoul, Korea
| | - Boo Kyung Han
- Department of Radiology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
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Turton P, El-Sharkawi D, Lyburn I, Sharma B, Mahalingam P, Turner SD, MacNeill F, Johnson L, Hamilton S, Burton C, Mercer N. UK Guidelines on the Diagnosis and Treatment of Breast Implant-Associated Anaplastic Large Cell Lymphoma (BIA-ALCL) on behalf of the Medicines and Healthcare products Regulatory Agency (MHRA) Plastic, Reconstructive and Aesthetic Surgery Expert Advisory Group (PRASEAG). Eur J Surg Oncol 2020; 47:199-210. [PMID: 33358076 DOI: 10.1016/j.ejso.2020.07.043] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2020] [Accepted: 07/23/2020] [Indexed: 01/11/2023] Open
Abstract
Breast implant-associated anaplastic large cell lymphoma (BIA-ALCL) is an uncommon T cell Non-Hodgkin Lymphoma (NHL) associated with breast implants. Raising awareness of the possibility of BIA-ALCL in anyone with breast implants and new breast symptoms is crucial to early diagnosis. The tumour begins on the inner aspect of the peri-implant capsule causing an effusion, or less commonly a tissue mass to form within the capsule, which may spread locally or to more distant sites in the body. Diagnosis is usually made by cytological, immunohistochemical and immunophenotypic evaluation of the aspirated peri-implant fluid: pleomorphic lymphocytes are characteristically anaplastic lymphoma kinase (ALK) negative and strongly positive for CD30. BIA-ALCL is indolent in most patients but can progress rapidly. Surgical removal of the implant with the intact surrounding capsule (total en-bloc capsulectomy) is usually curative. Late diagnosis may require more radical surgery and systemic therapies and although these are usually successful, poor outcomes and deaths have been reported. By adopting a structured approach, as suggested in these guidelines, early diagnosis and successful treatment will minimize the need for systemic treatments, reduce morbidity and the risk of poor outcomes.
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Affiliation(s)
- Philip Turton
- St James's Hospital, The Leeds Teaching Hospitals NHS Trust, Leeds, UK.
| | | | - Iain Lyburn
- Cobalt Medical Charity, Cheltenham, UK; Gloucestershire Hospitals NHS Foundation Trust, UK
| | | | | | - Suzanne D Turner
- Division of Cellular and Molecular Pathology, Department of Pathology, University of Cambridge, Cambridge, CB20QQ, UK; CEITEC, Masaryk University, Brno, Czech Republic
| | | | | | | | - Cathy Burton
- St James's Hospital, The Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Nigel Mercer
- Bristol Plastic Surgery, 58 Queen Square, Bristol, BS1 4LF, UK
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Invited Discussion on: Simultaneous Augmentation Mammoplasty and Vacuum-Assisted Breast Biopsy for Enhanced Cosmesis and Efficacy. Aesthetic Plast Surg 2020; 44:2048-2050. [PMID: 32875439 DOI: 10.1007/s00266-020-01925-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2020] [Accepted: 08/16/2020] [Indexed: 10/23/2022]
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Turton P, El-Sharkawi D, Lyburn I, Sharma B, Mahalingam P, Turner SD, MacNeill F, Johnson L, Hamilton S, Burton C, Mercer N. UK Guidelines on the Diagnosis and Treatment of Breast Implant-Associated Anaplastic Large Cell Lymphoma on behalf of the Medicines and Healthcare products Regulatory Agency Plastic, Reconstructive and Aesthetic Surgery Expert Advisory Group. Br J Haematol 2020; 192:444-458. [PMID: 33222158 PMCID: PMC7894347 DOI: 10.1111/bjh.17194] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2020] [Revised: 09/13/2020] [Accepted: 09/23/2020] [Indexed: 02/06/2023]
Abstract
Breast implant-associated anaplastic large cell lymphoma (BIA-ALCL) is an uncommon T-cell non-Hodgkin Lymphoma (NHL) associated with breast implants. Raising awareness of the possibility of BIA-ALCL in anyone with breast implants and new breast symptoms is crucial to early diagnosis. The tumour begins on the inner aspect of the peri-implant capsule causing an effusion, or less commonly a tissue mass to form within the capsule, which may spread locally or to more distant sites in the body. Diagnosis is usually made by cytological, immunohistochemical and immunophenotypic evaluation of the aspirated peri-implant fluid: pleomorphic lymphocytes are characteristically anaplastic lymphoma kinase (ALK)-negative and strongly positive for CD30. BIA-ALCL is indolent in most patients but can progress rapidly. Surgical removal of the implant with the intact surrounding capsule (total en-bloc capsulectomy) is usually curative. Late diagnosis may require more radical surgery and systemic therapies and although these are usually successful, poor outcomes and deaths have been reported. By adopting a structured approach, as suggested in these guidelines, early diagnosis and successful treatment will minimise the need for systemic treatments, reduce morbidity and the risk of poor outcomes.
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Affiliation(s)
- Philip Turton
- St James's Hospital, The Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | | | - Iain Lyburn
- Cobalt Medical Charity, Cheltenham, UK.,Gloucestershire Hospitals NHS Foundation Trust, Gloucester, UK
| | | | | | - Suzanne D Turner
- Division of Cellular and Molecular Pathology, Department of Pathology, University of Cambridge, Cambridge, UK.,CEITEC, Masaryk University, Brno, Czech Republic
| | | | | | | | - Cathy Burton
- St James's Hospital, The Leeds Teaching Hospitals NHS Trust, Leeds, UK
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Turton P, El-Sharkawi D, Lyburn I, Sharma B, Mahalingam P, Turner SD, MacNeill F, Johnson L, Hamilton S, Burton C, Mercer N. UK Guidelines on the Diagnosis and Treatment of Breast Implant-Associated Anaplastic Large Cell Lymphoma (BIA-ALCL) on behalf of the Medicines and Healthcare products Regulatory Agency (MHRA) Plastic, Reconstructive and Aesthetic Surgery Expert Advisory Group (PRASEAG). J Plast Reconstr Aesthet Surg 2020; 74:13-29. [PMID: 33483089 DOI: 10.1016/j.bjps.2020.10.064] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2020] [Accepted: 10/20/2020] [Indexed: 12/30/2022]
Abstract
Breast implant-associated anaplastic large cell lymphoma (BIA-ALCL) is an uncommon T cell Non-Hodgkin Lymphoma (NHL) associated with breast implants. Raising awareness of the possibility of BIA-ALCL in anyone with breast implants and new breast symptoms is crucial to early diagnosis. The tumour begins on the inner aspect of the peri-implant capsule causing an effusion, or less commonly a tissue mass to form within the capsule, which may spread locally or to more distant sites in the body. Diagnosis is usually made by cytological, immunohistochemical and immunophenotypic evaluation of the peri-implant fluid: pleomorphic lymphocytes are characteristically anaplastic lymphoma kinase (ALK) negative and strongly positive for CD30. BIA-ALCL is indolent in most patients but can progress rapidly. Surgical removal of the implant with the intact surrounding capsule (total en-bloc capsulectomy) is usually curative. Late diagnosis may require more radical surgery and systemic therapies and although these are usually successful, poor outcomes and deaths have been reported. By adopting a structured approach, as suggested in these guidelines, early diagnosis and successful treatment will minimize the need for systemic treatments, reduce morbidity and the risk of poor outcomes. These guidelines provide an evidence-based and systematic framework for the assessment and treatment of patients with suspected or proven BIA-ALCL and are aimed at all clinicians involved in the care of people with breast implants.
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Affiliation(s)
- Philip Turton
- St James's Hospital, The Leeds Teaching Hospitals NHS Trust, Leeds, UK.
| | | | - Iain Lyburn
- Cobalt Medical Charity, Cheltenham, UK; Gloucestershire Hospitals NHS Foundation Trust, UK
| | | | | | - Suzanne D Turner
- Division of Cellular and Molecular Pathology, Department of Pathology, University of Cambridge, Cambridge CB20QQ, UK; CEITEC, Masaryk University, Brno, Czech Republic
| | | | | | | | - Cathy Burton
- St James's Hospital, The Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Nigel Mercer
- Bristol Plastic Surgery, 58 Queen Square, Bristol BS1 4LF
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Sá Dos Reis C, Gremion I, Richli Meystre N. Consensus about image quality assessment criteria of breast implants mammography using Delphi method with radiographers and radiologists. Insights Imaging 2020; 11:56. [PMID: 32246276 PMCID: PMC7125279 DOI: 10.1186/s13244-020-00860-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2020] [Accepted: 03/05/2020] [Indexed: 12/03/2022] Open
Abstract
Aims To identify image quality criteria that can be applied to assess breast implant (BI) mammograms according to radiologists and radiographers’ perspectives and to explore the level of agreement about criteria priority. Methods A two-round Delphi method using a questionnaire was applied to identify the level of agreement between experts, asking them to rank each image criteria available for mammography according to 4 possible answers (1 = need to have, 2 = nice to have, 3 = not pertinent/appropriate, 4 = do not know). Criteria for craniocaudal (CC), mediolateral-oblique (MLO) and lateral (ML), with and without Eklund manoeuvre, were included. This process was repeated after removing the less relevant criteria. Results Between first and second rounds, different results were obtained regarding the criteria to assess CC and MLO images. Details for anatomic areas were considered the most relevant by radiographers during the first round, while general criteria were prioritised during the second round. Radiologists focused more on analysis of the spread of the breast tissue, if the breast was aligned with detector’s centre and level of contrast. The analysis of implant flow, the BI anterior edge and the maximum retropulsion of BI when Eklund manoeuvre is performed were the specific aspects of BI imaging considered as relevant for assessment. Conclusions The importance of each criterion used to assess BI mammograms was not the same between radiographers and radiologists, suggesting the two groups of experts are looking for different requirements from the image. Further education and training is necessary to align strategies for assessing BI mammograms, and some criteria need to be adapted to reduce subjectivity.
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Affiliation(s)
- Cláudia Sá Dos Reis
- School of Health Sciences (HESAV), University of Applied Sciences and Arts Western Switzerland (HES-SO), Av. de Beaumont 21, 1011, Lausanne, Switzerland. .,Discipline of Medical Radiation Sciences, School of Molecular and Life Sciences, Curtin University, GPO Box U1987, Perth, Western Australia, 6845, Australia. .,CISP - Centro de Investigação em Saúde Pública, Escola Nacional de Saúde Pública, Universidade NOVA de Lisboa, Lisbon, Portugal.
| | - Isabelle Gremion
- School of Health Sciences (HESAV), University of Applied Sciences and Arts Western Switzerland (HES-SO), Av. de Beaumont 21, 1011, Lausanne, Switzerland
| | - Nicole Richli Meystre
- School of Health Sciences (HESAV), University of Applied Sciences and Arts Western Switzerland (HES-SO), Av. de Beaumont 21, 1011, Lausanne, Switzerland
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Sá Dos Reis C, Gremion I, Richli Meystre N. Study of breast implants mammography examinations for identification of suitable image quality criteria. Insights Imaging 2020; 11:3. [PMID: 31900684 PMCID: PMC6942083 DOI: 10.1186/s13244-019-0816-5] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2019] [Accepted: 11/05/2019] [Indexed: 02/06/2023] Open
Abstract
PURPOSE To characterise the mammography technique used in breast cancer screening programmes for breast implants (BI) and to identify if the image quality (IQ) criteria available in literature are applicable to BI imaging. METHODS The study was conducted in two phases: literature review to find IQ criteria used in mammography combining keywords in several sources; and assessment of 1207 BI mammograms using the criteria that was identified previously to see if they were achieved or not. An observation grid was used to collect information about positioning, beam energy, compression force, and exposure mode. Descriptive statistics and Student's t test and χ2 test were performed according to the nature of the variables. RESULTS Forty-seven out of 2188 documents were included in the analysis, with 13 items identified to assess the quality of positioning, 4 for sharpness, 3 for artefacts, and 2 for exposure parameters. After applying the criteria to BI mammograms, retroglandular fat was not included in 37.3% of the images. The "Pectoral-Nipple-Line" criterion was achieved in 35% of MLO/ML images. The placement of the implant (subpectoral/subglandular) or performing the Eklund had significant influence on the visible anatomy (p = < 0.005), alongside whether the breast was aligned to the detector's centre. CONCLUSIONS Some of the criteria used to assess standard mammograms were not applicable to BI due to implant overlap. The alignment of the image with the detector's centre seems to have an impact on the amount of visible tissue. Further studies are necessary to define the appropriate protocol, technique, and suitable quality criteria to assess BI mammograms.
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Affiliation(s)
- Cláudia Sá Dos Reis
- School of Health Sciences (HESAV), University of Applied Sciences and Arts Western Switzerland (HES-SO), Av. de Beaumont 21, 1011, Lausanne, Switzerland.
- Discipline of Medical Radiation Sciences, School of Molecular and Life Sciences, Curtin University, GPO Box U1987, Perth, Western Australia, 6845, Australia.
- CISP - Centro de Investigação em Saúde Pública, Escola Nacional de Saúde Pública, Universidade NOVA de Lisboa, Lisbon, Portugal.
| | - Isabelle Gremion
- School of Health Sciences (HESAV), University of Applied Sciences and Arts Western Switzerland (HES-SO), Av. de Beaumont 21, 1011, Lausanne, Switzerland
| | - Nicole Richli Meystre
- School of Health Sciences (HESAV), University of Applied Sciences and Arts Western Switzerland (HES-SO), Av. de Beaumont 21, 1011, Lausanne, Switzerland
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