Pseudoangiomatous Stromal Hyperplasia of the Breast in a Female Adolescent Presenting as Bilateral Gigantomastia / 한국유방암학회지

Pseudoangiomatous stromal hyperplasia (PASH) is a rare idiopathic proliferative mesenchymal breast disease related to hormonal imbalance, and thus extremely rare in children and adolescents. In addition, PASH manifests as a bilateral gigantomastia in some cases with no established cause or treatment. Here, we report a case of a rapidly developed PASH presenting with bilateral gigantomastia in a 14-year-old premenarchial female patient.Considering the patient’s age and emotions and the need for nipple-areolar complex repositioning, we performed reduction mammoplasty rather than total mastectomy despite the possibility of recurrence. Although some masses could not be completely removed, no complications, such as infection, wound dehiscence, or hematoma occurred postoperatively.The patient was stable during the 18-month follow-up period, although an evidence of recurrent and residual disease was noted upon ultrasonography.

Specialty impact on residents’ perceived quality of life, stress, and job satisfaction: a comparative study

Purpose@#Specialty choice in residency training has a significant impact on an individual’s career and satisfaction, as well as the supply-demand imbalance in the healthcare system. The current study aimed to investigate the quality of life (QOL), stress, self-confidence, and job satisfaction of residents, and to explore factors associated with such variables, including postgraduate year, sex, and especially specialty, through a cross-sectional survey. @*Methods@#An online survey was administered to residents at 2 affiliated teaching hospitals. The survey had a total of 46 items encompassing overall residency life such as workload, QOL, stress, confidence, relationship, harassment, and satisfaction. Related survey items were then reconstructed into 4 key categories through exploratory factor analysis for comparison according to group classification. @*Results@#The weekly work hours of residents in vital and other specialties were similar, but residents in vital specialties had significantly more on-call days per month. Residents in vital specialties had significantly lower scores for QOL and satisfaction. Specifically, vital-surgical residents had significantly lower QOL scores and higher stress scores than the other specialty groups. Satisfaction scores were also lowest among vital-surgical residents, with a marginal difference from vital-medical, and a significant difference from other-surgical residents. Female residents had significantly lower satisfaction scores than their male counterparts. @*Conclusion@#Residents in vital specialties, particularly vital-surgical specialties, experience significantly worse working conditions across multiple dimensions. It is necessary to improve not only the quantity but also the quality of the system in terms of resource allocation and prioritization.

Preliminary results of alternative treatment for postmastectomy pain syndrome: stromal vascular fraction-enriched fat grafting

Postmastectomy pain syndrome (PMPS) is defined as chronic pain lasting more than 3 months after surgery. PMPS reduces the quality of life for patients and affects their daily life. Although the pathogenesis of PMPS has not been clearly elucidated, it is strongly suggestive of neuropathic pain caused by damage to the intercostobrachial nerve. While previous studies have used stromal vascular fraction (SVF)-enriched fat grafts in patients with neuralgia, few studies have used it for PMPS. Therefore, the present study evaluated the use of SVF-enriched fat, which includes adipose-derived stem cells with good differentiation capacity, in patients with PMPS to improve quality of life and reduce neuropathic pain. In three patients, the fat was mixed with concentrated SVF using a centrifuge and injected into the primary pain sites. After surgery, in all three cases, the subjective pain scale score decreased significantly over time.

Atypical rupture of a Poly Implant Prothése implant and fluid shifting: a case report

Women have undergone augmentation mammoplasty for decades, and if implant rupture is suspected, imaging modalities such as magnetic resonance imaging (MRI) and ultrasonography are available. The linguine sign, keyhole sign, and noose sign are all suggestive of rupture. However, earlier-generation implants with alternative filler materials demonstrate rupture signs that differ from those of today’s better-known implant materials. A 60-year-old female patient who had undergone augmentation mammoplasty 20 years ago presented with left breast swelling and pain in the lower-outer quadrant. Ultrasonography and MRI confirmed extracapsular diffuse wall enhancement with suspected, but not apparent, discontinuity in the patient’s left breast implant. Therefore, both implants were removed. It was determined that these were Poly Implant Prothése implants. The left breast implant differed from the contralateral implant in that it contained fluctuating fluid. This could be attributed to an osmotic gradient that caused the implant to swell and weakened the elastomer shell, resulting in micro rupture without a gross tear. Patients who undergo augmentation mammoplasty should have regular follow-up examinations, even if there are no symptoms. Furthermore, clinicians should be aware that some patients who have had breast augmentation mammoplasty may experience atypical symptoms and signs if the implant ruptures.

Breast implant-associated anaplastic large cell lymphoma: a case report with a history of spontaneously resolved late seroma

We report a case of breast implant-associated anaplastic large cell lymphoma (BIA-ALCL), which had a history of spontaneous resorption of late seroma before diagnosis. A 47-year-old woman with a history of augmentation mammoplasty with round textured implants in January 2013 presented with a swelling on her right breast 6 years later, which was diagnosed as late seroma with suspected intracapsular rupture using ultrasonography (USG). Although aspiration was not done at the time of the initial USG, the seroma resolved spontaneously within weeks. A further workup proceeded with USG-guided aspiration followed by magnetic resonance imaging. Cytology of the aspirated fluid showed atypical cells. Cell block cytology and immunohistochemical staining confirmed the diagnosis of BIA-ALCL. En bloc resection with total capsulectomy and explantation was performed as curative surgery. Pathologic stage pT2N0M0 was confirmed and the patient was followed up without further treatment. Although the classic presentation of BIA-ALCL is known as late persistent seroma, an atypical manifestation such as spontaneous resorption may occur, as in the current case. A high level of suspicion and a thorough investigation with appropriate modalities will make it possible to detect this rare and potentially devastating disease.

Recurrence of Breast Carcinoma as Paget's Disease of the Skin along the Core Needle Biopsy Tract after Skin-Sparing Mastectomy / 한국유방암학회지

We report a case of recurrence as Paget's disease at the core needle biopsy (CNB) entry site in a patient with microinvasive ductal carcinoma who underwent nipple-areola-skin sparing mastectomy (NASSM) and autologous reconstruction. Clinically diagnosed recurrences associated with previous needle procedures for malignant breast lesions are rare and usually occur in patients who have not received radiation therapy. The present case involved local recurrence at the skin puncture site of a patient diagnosed based on CNB findings who underwent NASSM without receiving radiation therapy. Although the removal of the CNB tract with resected breast tissue is not always emphasized, the skin puncture site should be recorded to detect abnormal skin changes after surgery for the timely detection and management of complications.

Current status of and trends in post-mastectomy breast reconstruction in Korea

Since April 2015, post-mastectomy breast reconstruction has been covered by the Korean National Health Insurance Service (NHIS). The frequency of these procedures has increased very rapidly. We analyzed data obtained from the Big Data Hub of the Health Insurance Review and Assessment Service (HIRA) and determined annual changes in the number of breast reconstruction procedures and related trends in Korea. We evaluated the numbers of mastectomy and breast reconstruction procedures performed between April 2015 and December 2018 using data from the HIRA Big Data Hub. We determined annual changes in the numbers of total, autologous, and implant breast reconstructions after NHIS coverage commenced. Data were analyzed using Microsoft Excel. The post-mastectomy breast reconstruction rate increased from 19.4% in 2015 to 53.4% in 2018. In 2015, implant reconstruction was performed in 1,366 cases and autologous reconstruction in 905 (60.1% and 39.8%, respectively); these figures increased to 3,703 and 1,570 (70.2% and 29.7%, respectively) in 2018. Free tissue transfer and deep inferior epigastric perforator flap creation were the most common autologous reconstruction procedures. For implant-based reconstructions, the rates of directto-implant and tissue-expander breast reconstructions (first stage) were similar in 2018. This study summarizes breast reconstruction trends in Korea after NHIS coverage was expanded in 2015. A significant increase over time in the post-mastectomy breast reconstruction rate was evident, with a trend toward implant-based reconstruction. Analysis of data from the HIRA Big Data Hub can be used to predict breast reconstruction trends and convey precise information to patients and physicians.

Outcomes of saline implant-based immediate breast reconstruction: 15-year follow-up results

Background@#Although rarely used at present in South Korea, saline implants accounted for most of the implants used from 1992 to 2007. However, few studies have reported on the long-term outcomes of saline implants, especially in breast reconstruction. We analyzed the long-term outcomes of patients who underwent direct-to-saline implant reconstruction. @*Methods@#This retrospective study included patients who underwent saline implant-based immediate breast reconstruction between 2003 and 2007. The patients’ demographic information, medical history, operative/implant details, and oncologic data were collected. Early and late complications, reoperations, and final outcomes of the implant (maintenance, explantation, exchange, and autologous conversion) were analyzed to determine the long-term results and to identify factors affecting the outcomes. @*Results@#Early complications (within 90 days) were noted in 19.5% of patients and late complications (after 90 days) occurred in 29.3% of patients. The most common early complications were skin necrosis and delayed healing, whereas the most common late complications were rippling or visibility and capsular contracture. Of the implants, 22% were replaced (12%) or converted to autologous tissue (10%). The factors that influenced the final outcomes were patient age, nipple-areola-sparing procedure, breast size, implant fill volume, and implant manufacturer. @*Conclusions@#Patients who previously received saline implants still visit the clinic for consultations. This long-term follow-up study with few dropouts reflects the real needs of reconstruction patients. Our results provide useful information for consulting with patients who already have saline implants or those who request for as much information about available implant options as possible.

Psychological characteristics of adult neurofibromatosis type 1 patients seeking elective surgery

Background@#Neurofibromatosis type 1 (NF1) is an autosomal dominant genetic disorder involving the nervous system characterized by the development of neurofibromas throughout the body. Patients with NF1 are also known to have cognitive, behavioral, social, and emotional problems. Using the Symptom Checklist-90-Revision (SCL-90-R) questionnaire, we aimed to assess the psychological characteristics of NF1 patients seeking surgery at a tertiary hospital. @*Methods@#Adult NF1 patients visiting a plastic surgery outpatient clinic between March 2018 and March 2020 were enrolled in this study. The presence and intensity of psychopathological symptoms were assessed using 10 domains, including the General Severity Index (GSI). Standard T-scores were used to compare the results to population-based norms. The impact of demographic factors was also analyzed. @*Results@#In total, 65 patients were included in the study. The mean GSI of all patients was 43.7, and the mean score of the other nine domains was 45.3. No scores deviated from the population-based normal ranges. Nonetheless, women had significantly higher mean T-scores than men in a few domains, including the GSI, obsessive-compulsive disorder, depression, and anxiety. Most of the other characteristics, such as age, education, marital status, family history, and tumor site did not have significant effects. @*Conclusions@#Adult NF1 patients who visit plastic surgery clinics for elective surgery have psychopathological characteristics that do not differ from the general population according to the SCL-90-R. The results of this study can be considered in consultations with these patients.

Bilateral Metachronous Paget's Disease of the Accessory Breasts in a Male / 한국유방암학회지

Bilateral axillary Paget's disease in men is a rare occurrence with limited reports on its diagnosis, treatment, and prognosis. Here, we report the case of a 55-year-old Korean male, who presented with a palpable mass and eczematous skin lesion on the left axilla. An incisional biopsy and histopathologic examination indicated invasive ductal carcinoma with Paget's disease arising in the accessory breast. Magnetic resonance imaging and positron emission tomography revealed no malignancy in the normal breast and other organs. The patient was subjected to a wide excision, wherein the left axillary lymph node was dissected, followed by the administration of adjuvant chemotherapy and radiation therapy. After 17 months of disease-free survival, the patient was diagnosed with Paget's disease of the contralateral accessory breast. He underwent wide excision surgery along with radiation therapy. To the best of our knowledge, this is the first report of bilateral extramammary Paget's disease in a male.

Bilateral Metachronous Paget's Disease of the Accessory Breasts in a Male / 한국유방암학회지

Bilateral axillary Paget's disease in men is a rare occurrence with limited reports on its diagnosis, treatment, and prognosis. Here, we report the case of a 55-year-old Korean male, who presented with a palpable mass and eczematous skin lesion on the left axilla. An incisional biopsy and histopathologic examination indicated invasive ductal carcinoma with Paget's disease arising in the accessory breast. Magnetic resonance imaging and positron emission tomography revealed no malignancy in the normal breast and other organs. The patient was subjected to a wide excision, wherein the left axillary lymph node was dissected, followed by the administration of adjuvant chemotherapy and radiation therapy. After 17 months of disease-free survival, the patient was diagnosed with Paget's disease of the contralateral accessory breast. He underwent wide excision surgery along with radiation therapy. To the best of our knowledge, this is the first report of bilateral extramammary Paget's disease in a male.

Frozen-thawed Abdominal Flap Remnant as an education material for a Medium Group Surgical Skills Education Workshop

PURPOSE: Residents' duty-hour regulations and the evolution of minimally invasive surgical techniques require more effective and efficient surgical skill teaching models. We used frozen-thawed human tissue remnants harvested during abdominoplasty or abdominal tissue-based breast reconstruction to allow for a medium-sized group workshop program, simulating a realistic surgical environment and visual/haptic feedback. METHODS: Full-thickness abdominal tissue (skin and subcutaneous fat) were donated from patients who underwent autologous breast reconstruction and gave consent to use their tissue for comprehensive research and medical educational purposes. Anonymized tissue was frozen-preserved and then thawed the day of the surgical skills workshop. A total of 53 residents completed 50-minute hands-on training in 3-to-5 person modules in four sessions of the workshop program. RESULTS: Thawed tissue regained almost normal texture and consistency. Structural integrity was also histologically confirmed. All participants were generally satisfied with the program, especially regarding the suture material provided. CONCLUSION: Frozen-thawed tissue remnants from abdominoplasty or autologous breast reconstruction could be preserved and used as a suture education material in medium-group workshops for surgery residents or medical students given anonymity and with proper consent guaranteed. This approach provided an excellent model maintaining relatively real anatomic structure and consistency with minimal cost.

Skin-sparing Mastectomy and Immediate Nipple Graft for Large, Ptotic Breast / 한국유방암학회지

Appropriate Prophylactic Antibiotic Use in Clean Wound Surgery Under Local Anesthesia

BACKGROUND: Although guidelines to prevent surgical site infections (SSIs) were published more than a decade ago, prophylactic antibiotics are still used subjectively in clinical practice. In this study, we evaluated the safety of single-dose preoperative intravenous antibiotics without postoperative antibiotics in the field of clean wound surgery performed under local anesthesia. We also surveyed the present clinical conditions for prophylactic antibiotic use in the plastic surgery departments of training hospitals in Korea. METHODS: A total of 360 consecutive patients who underwent clean wound surgery under local anesthesia in an outpatient clinic from March 2018 to October 2018 were reviewed. In the study group, a single surgeon administered first-generation cephalosporins intravenously within 1 hour of skin incision and did not prescribe additional antibiotics. In the control group, 2 other surgeons prescribed oral first-generation cephalosporins postoperatively for 2 to 3 days without preoperative antibiotics. A telephone survey about perioperative antibiotic regimens was conducted at the departments of plastic surgery in training hospitals. RESULTS: There were 128 patients in the study group and 232 patients in the control group. There were no significant differences between the 2 groups regarding SSIs and other surgical complications. A total of 41 training hospitals answered the survey and every hospital had protocols of prescribing postoperative oral antibiotics routinely at the time of discharge with a mean duration of 3.9 days. Only 11 hospitals (26.8%) prescribed parenteral antibiotics before surgery as well as postoperative oral antibiotics. CONCLUSION: Intravenous injection of single-dose first-generation cephalosporins 1 hour before surgery without postoperative antibiotics did not increase the incidence of SSIs compared with the usual practice of giving only postoperative antibiotics prescription for 2 to 3 days in cases of clean wound surgery performed under local anesthesia. Proper antibiotic prophylaxis should be performed by surgeons in training hospitals without hesitation.

The Goldilocks technique: An alternative method to construct a breast mound after prosthetic breast reconstruction failure

The Goldilocks technique for breast reconstruction utilizes redundant mastectomy flap tissue to construct a breast mound. This technique is suitable for women who decline, or are poor candidates for, traditional postmastectomy reconstruction. Moreover, this technique can be applied in secondary operations after the failure of initial reconstruction efforts. A 74-year-old patient underwent the Goldilocks procedure after reconstruction failure with an implant and acellular dermal matrix. At her 6-month follow-up, the cosmetic outcome of the procedure was satisfactory, and no complications were noted. Therefore, the Goldilocks procedure is a safe alternative to reconstruct breast mounds following reconstruction failure, especially in obese patients.

Microsurgical options after the failure of left colon interposition graft in esophagogastric reconstruction

Colon interposition is commonly used for esophageal reconstruction in patients with a previous gastrectomy. However, when colon interposition fails and alternative reconstruction is required, there are few options for reconstructing the long segment from the esophagus to the stomach. Here, we report on cases of esophagogastric reconstruction with limited alternative options after the failure of transverse and left colon interposition. In these cases, reconstruction was performed using two different microvascular methods: double-pedicle jejunal free flap and supercharged ileocolic interposition graft.

Volumetric changes of the pedicled transverse rectus abdominis musculocutaneous flap and the contralateral native breast during long-term follow-up

BACKGROUND: Serial volumetric changes of reconstructed breasts have not been studied in detail. In this study, we analyzed serial volumetric changes of reconstructed and contralateral normal breasts during long-term follow-up, with a focus on the effect of various adjuvant therapies. METHODS: Among all patients who underwent immediate breast reconstruction with a unilateral pedicled transverse rectus abdominis musculocutaneous (p-TRAM) flap, 42 patients with valid data from ≥3 postoperative positron emission tomography-computed tomography (PET-CT) scans were included. The volumes of the reconstructed and normal breasts were measured, and the ratio of flap volume to that of the contralateral breast was calculated. Serial changes in volume and the volume ratio were described, and the effects of chemotherapy, radiation therapy, and hormone therapy on volumetric changes were analyzed. RESULTS: The mean interval between the initial reconstruction and each PET-CT scan was 16.5, 30, and 51 months respectively. Thirty-five, 36, and 10 patients received chemotherapy, hormone therapy, and radiation therapy, respectively. The flap volume at each measurement was 531.0, 539.6, and 538.0 cm3, and the contralateral breast volume was 472.8, 486.4, and 500.8 cm3, respectively. The volume ratio decreased from 115.1% to 113.4%, and finally to 109.6% (P=0.02). Adjuvant therapies showed no significant effects. CONCLUSIONS: We demonstrated that the p-TRAM flap maintained its volume over a long-term follow up, while the volume of the contralateral native breast slowly increased. Moreover, adjuvant breast cancer therapies had no statistically significant effects on the volume of the reconstructed p-TRAM flaps or the contralateral native breasts.

Single vertical incision thoracoabdominal flap for chest wall reconstruction following mastectomy of locally advanced breast cancer

PURPOSE: Skin grafts have been widely used in managing extensive chest wall defects after mastectomy for advanced breast cancer. However, their durability and tolerability to radiotherapy is still controversial. A thoracoabdominal (TA) flap with a few technical refinements can safely transfer a larger flap while minimizing complications. METHODS: From January 2007 to February 2018, a retrospective review was performed to compare 2 groups after wide breast excision: skin graft group (group 1) and lateral-based, single vertical incision rotation-advancement TA flap (group 2). Patients' demographics, operative details, complications, hospital stay, postoperative outpatient visits, cost, and start of adjuvant therapy were analyzed between the 2 groups. RESULTS: During the study period, 34 patients received skin graft and 41 patients received TA flap. group 2 had a shorter hospital stay (6.41 ± 2.64 days vs. 12.62 ± 4.60 days, P 1 year was observed in 4 patients in only group 1 (43.90% vs. 38.24%, P = 0.613). CONCLUSION: TA flap has a simple design that minimizes concerns involving the donor site. Moreover, it does not require complicated procedures and allows for re-elevation whenever necessary. Finally, it guarantees faster wound recovery than skin graft with fewer complications.

Unilateral pedicled transverse rectus abdominis musculocutaneous flap and unilateral free deep inferior epigastric artery perforator flap as a surgical alternative in bilateral autologous breast reconstruction

BACKGROUND: Bilateral microsurgical autologous reconstruction is known to increase operating time, costs, and complications compared to unilateral procedures. This study aimed to determine whether a unilateral pedicled transverse rectus abdominis myocutaneous (TRAM) flap and a unilateral deep inferior epigastric artery perforator (DIEP) free flap could be a feasible option for bilateral reconstruction in selected circumstances. METHODS: A retrospective chart review identified patients who underwent unilateral pedicled TRAM and unilateral DIEP reconstruction for bilateral breast reconstruction between 2011 and 2014. Surgical outcomes, complications, and aesthetic scale questionnaire responses were evaluated. RESULTS: Fourteen patients were included in this study. Ten patients received bilateral immediate reconstruction, while four patients with a previous history of mastectomy underwent unilateral immediate reconstruction and contralateral delayed reconstruction. All flaps survived without any major complications. A case of nipple-areolar skin necrosis on the pedicled TRAM side and a case of mild abdominal bulging at the free DIEP donor site were reported. There was no partial flap necrosis or palpable fat necrosis. On the aesthetic outcome scale, the free DIEP flaps scored significantly higher than did the pedicled TRAM flaps for overall shape, the upper medial and lower lateral quadrant, and the lateral chest wall. CONCLUSIONS: Our findings suggest that a unilateral pedicled TRAM flap together with a unilateral free DIEP flap could be performed as a bridging surgical option as institutions move toward bilateral free-flap reconstructions, as a way to reduce operating time and the risk of microsurgery-related complications with acceptable donor site morbidity and aesthetic outcomes.

Local Subcutaneous Injection of Erythropoietin Might Improve Fat Graft Survival, Whereas Continuous Infusion Using an Osmotic Pump Device Was Harmful by Provoking an Overwhelming Foreign Body Reaction in a Nude Mouse Model

BACKGROUND: Since the survival of grafted fat requires successful revascularization, we hypothesized that local delivery of erythropoietin (EPO), a hemangiogenic and antiapoptotic factor, might enhance the survival of fat grafts in a nude mouse model. METHODS: Our experiment consisted of 2 parts. The first involved direct injection of EPO or saline at the grafting site before fat grafting and for 4 days afterwards. In the second part, EPO or saline was delivered continuously for 1 week via an osmotic pump device, and a group without an implantable pump represented the control group. After 16 weeks, the surviving fat grafts were weighed and subjected to histomorphometry. RESULTS: In the first experiment, fat graft survival was higher in the EPO-injected group, but not statistically significant (69.2% vs. 59.2%; P=0.21). Histomorphometry showed significantly higher levels of microvessel formation and less cystic degeneration in the EPO-injected group. In the second experiment, the survival rate was significantly lower in both pump groups than in the control group (40.7% in the EPO pump group, 7.7% in the saline pump group, and 66.7% in the control group). CONCLUSIONS: Local injection of EPO into the fat graft site appeared to improve graft survival, with increased angiogenesis, suppressed inflammation, and decreased degeneration. However, the insertion of an osmotic pump exerted detrimental effects on graft survival and the histomorphometric profiles of the fat graft compared with the control group due to the overwhelming foreign body reaction.