Vitiligo as a Köebner phenomenon after oncoplastic breast surgery

The Köebner phenomenon is characterized by the appearance of several types of dermatological lesions after traumatic stimulation. The triggering of this phenomenon after breast surgery is uncommon and usually associated with psoriatic lesions. The aim of this study was to describe two cases of vitiligo as the initial manifestation of Köebner phenomenon after breast oncoplastic surgery. Case 1: female, 41 years old, no history of dermatological pathologies, presenting with tubular carcinoma in the right breast. Quadrantectomy and sentinel lymph node biopsy were performed, followed by reconstruction with mammoplasty. Later, the patient started on tamoxifen and underwent radiotherapy, without complications. Thirty days after treatment, the patient presented progressive depigmentation of the areola-papillary complex. Topical treatment was started with dermatological ointment tacrolimus monohydrate and, after one year, the condition was completely resolved. Case 2: 52-yearold woman with previous history of vitiligo on the face, with complete clinical response after dermatological treatment. She was diagnosed with ductal carcinoma in situ on the left breast and underwent quadrantectomy, by means of mammoplasty using the round block technique. Afterwards, she underwent radiotherapy and started tamoxifen. Four years after the surgery, she developed dyschromia in the ipsilateral periareolar region and was diagnosed with vitiligo. Local dermopigmentation was offered, but the patient opted for an expectant conduct and clinical follow-up. To our knowledge, this is the first description of Köebner phenomenon after breast oncoplastic surgery. In these cases, the therapeutic approach must be multidisciplinary and count on the assessment of multiple clinical and individual parameters.

Reconstrucción inmediata con expansores anatómicos: un abordaje factible para obtener buenos resultados / Inmediate breast reconstruction with anatomical expanders: an approach feasible to obtain good results

Hay evidencia sobre los beneficios de la reconstrucción inmediata posterior a una mastectomía. Objetivo: Evaluar nuestra experiencia con expansores anatómicos en la reconstrucción mamaria inmediata. Métodos: Este estudio incluyó 60 pacientes consecutivos de la base de datos de CECLINES en Caracas-Venezuela(2009-2013), en los cuales se realizó una reconstrucción inmediata con expansor anatómico (RIEA). Información antropométrica y quirúrgica fue prospectivamente recolectada. La evaluación cosmética consistió en una escala de cinco puntos, registrada durante el seguimiento. La escala numérica análoga (ENA) asentó la sensación de dolor durante la expansión en una escala de diez puntos. Las indicaciones para una RIEA fueron: La necesidad de radioterapia (Rt), la necesidad de un implante >300cc para una reconstrucción de 1 etapa y en caso de un músculo pectoral mayor delgado que no permita la confección de una cobertura muscular total para un implante. Resultados:La edad promedio de los pacientes fue 48.5 años (DE 10.5). El seguimiento promedio fue de 23.5 meses (11-60). El tamaño promedio del tumor fue 40mm (DE 22). En 33.3% (20/60) de los pacientes se realizó una mastectomía con conservación del complejo areola-pezón, con una necrosis del CAP del 5%(1/20). El promedio del índice de masa corporal (IMC) fue de 26.3 Kg/m2(DE 4.5). El 90% de las puntuaciones cosméticas fueron 4-5 (bien-excelente), con una tasa de participación del 73%(44/60). En la puntuación recolectada por la ENA el 39% de las pacientes no presentó dolor y un 10% presentó dolor de fuerte intensidad o intolerable. La tasa global de complicación fue del 20% (12/60). Las complicaciones más frecuentes fueron: Contractura capsular 5%, infección 6.6% y hematoma 3.3%. Un IMC >30 Kg/m2 estuvo relacionado con mayor probabilidad para complicaciones (OR = 4.6; CI 95%: 1.2 ­ 18.1, p=0.021). La Rt no fue una variable que atribuyera más riesgo para complicaciones (OR = 1.4; CI 95%: 0.4 ­ 4.9, p = 0.826). La tasa de extrusión de expansores fue del 10%. La colocación de un expansor >500 cc fue un factor de riesgo para extrusión sin significancia estadística (RR=6.0, IC 95% 0.74-48.59, p=0.0932; OR=6.8,IC 95% 0.74-61.88, p=0.088). La tasa de extrusión de implante en la segunda etapa de la reconstrucción fue 3.7%. Conclusión:La RIEA es un excelente abordaje en pacientes seleccionados,alcanzando una baja cifra de complicaciones, con baja tasa de extrusión y proporcionando un buen resultado estético. Los pacientes obesos deben ser advertidos sobre la elevada probabilidad de complicaciones dada su condición(AU)

There is evidence on the benefits of immediate breast reconstruction following a mastectomy. Objective:The aim of this study is to evaluate our experience with anatomical expanders in immediate breast reconstruction. Methods:This study included 60 consecutive patients from CECLINES ́ database in Caracas,Venezuela (2009-2013), in which an immediate breast reconstruction with anatomical expander (IBRAE) was performed.Anthropometric and surgical data was prospectively collected.Cosmetic evaluation consisted of a five-point scale, recorded during follow-up. Analog numerical scale (ENA) established the sensation of pain during expansion in a tenpoint scale. The instructions for IBRAE were: The need for radiotherapy (RT), the need for an implant> 300cc for a reconstruction of one stage and if a thin major pectoral muscle that does not allow making full muscle coverage for an implant-based reconstruction. Results: The mean age of patients was 48.5 years (SD 10.5). The average follow-up was 23.5 months (11-60). The average tumor size was 40 mm (SD 22). In 33.3% (20/60) of patients a nipple-sparing mastectomy was performed with a nipple-areola complex necrosis of 5% (1/20). The average body mass index (BMI) was 26.3 kg /m2 (SD 4.5). The 90% of cosmetic scores were 4-5 (good-excellent), with a participation rate of 73% (44/60). In the rating collected by the ENA 39% of the patients had no pain and 10%had high-intensity pain or intolerable. The overall complication rate was 20% (12/60). The most frequent complications were: capsular contracture to 5%, infection 6.6% and 3.3% hematoma.A BMI> 30 kg / m2 was associated with greater likelihood for complications (OR = 4.6; 95% CI: 1.2 - 18.1, p = 0.021). The Rt was not a variable that attributed risk for complications (OR = 1.4;95% CI: 0.4 - 4.9, p = 0.826). The extrusion rate was 10% for expanders. The placement of an expander > 500cc was a risk factor for extrusion without statistical significance (RR = 6.0, 95% CI0.74-48.59, p = 0.0932, OR = 6.8, 95% CI 0.74-61.88, p =0.088). The extrusion rate of implant in the second stage of reconstruction was 3.7%. Conclusion: IBRAE is an excellent approach in selected patients, reaching a low rate of complications, low extrusion rate and providing a good cosmetic outcome.Obese patients should be warned about the high likelihood of complications due to their condition(AU)