Simultaneous correction of breast hypertrophy and vaginal agenesis: Aesthetic surgery to the aid of reconstructive surgery.

Mayer-Rokitansky-Küster-Hauser syndrome is characterized by aplasia of the uterus and the upper ⅔ of the vagina, with normal female genotype (46,XX) and the development of secondary sexual characters. One of the most popular surgical treatment is the McIndoe procedure, which major drawbacks are the scar of split thickness skin graft (STSG)harvesting, and risk of vaginal stenosis for graft retraction. We report the case of a patient, operated modifying the McIndoe technique, by harvesting a full thickness skin grafts (FTSG) from patient's breasts, undergone simultaneous reduction mammoplasty. The FTSG provided a complete lining of the reconstructed neovagina. At 6 months, we observed complete mucinous metaplasia of the vaginal walls and 1 year after surgery no sign of stenosis, without the use of the mold. The advantages of this technique are reduced donor site morbidity, when compared with traditional McIndoe technique, and reduced risk of neovagina retraction ensured by FTSG, compared with STSG. If future patients' series confirm the good results achieved, we could consider it as a first-line option in patients undergoing neovagina reconstruction, seeking breasts or body contouring surgery.

Insurance Appeals for Pediatric Reconstructive Surgery: A Micro Cost Analysis and How-to Guide.

BACKGROUND: When insurance coverage for pediatric reconstructive procedures is denied, a stressful and time-consuming appeals process ensues. This article discusses the results of a micro cost analysis performed to better understand the time and monetary burden that the insurance process places on our clinic and families. We also advise plastic surgeons on how to appeal insurance denials for necessary reconstructive procedures. METHODS: Our micro cost analysis focused on patients with congenital breast anomalies who were denied insurance coverage during the preservice insurance authorization process. We surveyed staff and family members to determine the steps involved in the insurance process and how long each person spent on each step. We combined this with average compensation data to calculate cost. RESULTS: For the 5 patients included in our analysis, the insurance process took an average of 7.4 hours of institutional time and cost $521.43 per patient. All patients were denied coverage during prior authorization and required a peer-to-peer, and all denials occurred because surgery was deemed cosmetic or not medically necessary. CONCLUSIONS: This analysis estimated the time and monetary cost of the insurance process in our department. Access to care was limited by prior authorization and the opinion of medical directors that these procedures are unnecessary or cosmetic. We encourage plastic surgeons to continue to perform patient-centered outcomes research in their practice to build on literature that proves the functional and psychosocial benefits of reconstructive procedures.

Tuberous Breast: Past, Present, and Future: Personal Classification, Treatment, and Surgical Outcomes.

BACKGROUND: Tuberous breast (TB) is a rare congenital deformity, which may appear in different clinical forms representing various degrees of a single pathological entity. The worst cases are characterized by severe hypoplasia. Following a detailed analysis of the available relevant literature and a significant number of treated cases, in this article, the authors propose a new classification, with the aim of summarizing and simplifying a more intuitive categorization of the malformation, considering all the clinical aspects and including all types of TBs, even the minor ones, thus allowing a more immediate diagnosis and surgical planning. METHODS: Between September 2006 and December 2015, 78 patients with TBs underwent surgical procedures to correct the deformity. The patients' mean age was 18.6 years, ranging between 17 and 26 years. There being 11 monolateral deformities, the treated TBs amounted to 145. A periareolar approach, adipo-glandular flaps, and dual plane breast implant placements were performed. Postoperative follow-up include photos collected 12 months after operation. The authors present a personal classification including all the forms of the deformity, plus the minor forms based on the following 2 principal categories: hypoplastic and normoplastic TBs, taking into account all the clinical aspects of the malformation including the morphology and the consistency of the breast. CONCLUSIONS: Preoperative identification of the type of the deformity is essential to obtain satisfactory results and a complete and intuitive classification including all the possible variants of the deformity, even the minor forms, and fundamental in diagnosing and resolving the problem. In this article, the authors propose a personal classification and surgical procedure to resolve the malformation.

[EFFECTIVENESS OF ROTATION-EMBEDDING TECHNOLOGY FOR TREATMENT OF MODERATE TO SEVERE INVERTED NIPPLES].

OBJECTIVE: To investigate the effectiveness of rotation-embedding technology for treatment of moderate to severe inverted nipples. METHODS: Between March 2012 and March 2014, 24 patients (39 nipples) with moderate to severe inverted nipples were treated using rotation-embedding technology. The age ranged from 28 to 42 years (mean, 32 years). The bilateral nipples involved in 15 cases, unilateral nipple in 9 cases, including 30 moderate inverted nipples, 9 severe inverted nipples. The first time operation was performed in the other patients except 1 patient who had received corrective operation of bilateral nipples. RESULTS: The operation was successfully performed in all patients; primary healing of incision was obtained; no swollen, bleeding, dehiscence, or blood flow obstacle occurred. All patients were followed up 5-24 months (mean, 12 months). The shapes of nipples were satisfactory; bilateral nipples were symmetrical basically; no nipple inversion recurred, and the nipple skins had good sensation. CONCLUSION: Using rotation-embedding technology can correct moderate to severe inverted nipples effectively.

Surgical Strategies in the Correction of the Tuberous Breast.

Management of the tuberous breast represents one of the greatest surgical challenges in aesthetic breast surgery, requiring careful assessment and a methodical approach to obtain an acceptable result. The surgeon must be familiar with multiple techniques that can be performed individually or may be combined to address various aspects of the tuberous deformity. This article describes the etiology, anatomic features, identification, and classification of the tuberous breast, focusing on surgical management and potential pitfalls. Through case study, expected outcomes in the management of this complex problem are described.

An easy way for congenital symmastia correction.

UNLABELLED: Congenital symmastia is described as a connection between the breasts without macromastia. In this condition, there is accumulation of fat and glandular tissue between the breasts, which produces a unified appearance of the breast tissue across the chest. We report a case of congenital symmastia in a 21-year-old woman with normal-sized and -shaped breasts. We achieved satisfying aesthetic results using suction-assisted lipectomy and the patient's complaint was resolved without scar or major surgery. LEVEL OF EVIDENCE V: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

The use of lipofilling to treat congenital hypoplastic breast anomalies: preliminary experiences.

BACKGROUND: Treatment options for congenital hypoplastic breast anomalies are often open, including radial scoring, parenchymal flaps, and insertion of expanders and implants. Drawbacks of open techniques involve scarring, the use of drains, and inpatient stays. The use of lipofilling to treat breast deformities is increasing, as more research is completed in this area. PATIENTS AND METHODS: We report a retrospective study of 10 patients below the age of 20 following autologous fat transfer between January 1, 2003 and January 1, 2004. (2 Poland syndrome, 3 bilateral tuberous breast, and 5 unilateral micromastia). Age, cup size, the number of sessions, time interval between each session, volumes injected, and complications were recorded. Postoperative mammography, ultrasonography, and MRI were assessed by a specialized radiologist. Patients answered a questionnaire 1 year after the procedure. RESULTS: Mean follow-up was 68 months (60-77 months) and mean age was 17.5 years (15-20 years). Mean number of fat injection sessions was 2 (1-4) and mean volume injected 285 mL per breast (200-500 mL). The time interval between each session was 5 months (3-6 months). Cup size remained unchanged after at least 5 years of follow-up. One case underwent a contralateral breast reduction. The cosmetic results considered satisfactory in almost all the patients after 1 year of follow-up. None of our patients complained of scars or defects at the donor site. All breasts imaging were normal except 1 patient with oil cysts. CONCLUSION: Our preliminary results using lipofilling to treat young patients with breast hypoplasia with lipofilling are very encouraging. The authors believe it is an alternative of choice for the correction of the young woman's breast deformities if the avoidance of scarring is preferred.

Bilateral congenital amazia: a case report and systematic review of the literature.

BACKGROUND: Congenital breast anomalies present challenging management decisions to the plastic surgeon. One must consider the optimal age of reconstruction as well as the ideal surgical technique. Amazia, a very rare condition characterised by a complete lack of breast tissue in the presence of a nipple areolar complex (NAC), is one such congenital breast anomaly. METHODS: A comprehensive systematic review of the literature was performed to examine the various approaches to reconstruction of congenital breast anomalies. From this review, the data compiled included patient demographics and operative details, including type of reconstruction, treatment of the contralateral breast and treatment of the NAC. A case of bilateral amazia is also reported. RESULTS: Of 178 articles, 13 ultimately met the inclusion criteria and 54 individual patient reconstructions were identified from these papers. At the time of reconstruction, the patients were in the range of 13-54 years, with an average age of 27.6 years. Prosthetic and autologous reconstructions were equally represented (19 patients each, 35.2%; Table 2). Autologous reconstruction with prosthesis was slightly less common (15 patients, 27.8%). One patient was reconstructed using autologous lipo-augmentation only. Of the 36 cases in which the approach to the NAC was addressed, most (66.7%) were not reconstructed. CONCLUSIONS: Amazia is a very rare congenital anomaly of the breast. This systematic review of the literature highlights the need for better reporting and examination of this type of data to allow for future study and to better advise on decision making regarding the timing of reconstruction, surgical technique and the approach to the NAC.

[Continuous traction treatment for correction of inverted nipple with self-made adjustable tractor].

OBJECTIVE: To explore the effectiveness of self-made adjustable tractor for correction of inverted nipple. METHODS: Between March 2005 and March 2011, 37 female patients with inverted nipples (69 nipples) underwent continuous traction with self-made adjustable tractor for 2 to 4 months. The age ranged from 18 to 46 years (mean, 23 years). Of 37 cases, 5 had unilateral inverted nipple, and 32 had bilateral inverted nipples, including 8 cases (15 nipples) of mild inversion, 16 cases (30 nipples) of moderate inversion, and 13 cases (24 nipples) of severe inversion. The 2 cases (4 nipples) recurred after traditional surgical method, and 1 case (2 nipples) had infection because of severe inversion before traction. RESULTS: No infection or hemodynamic disorder occurred during traction. All cases were followed up 6-12 months (mean, 8.2 months). Wound healed after traction in 1 patient (2 nipples) with infection because of severe inversion; 2 recurrent cases (2 nipples) were cured after re-traction; wire dislocation occurred in 1 case (1 nipple), and was cured after changing traction position. The shape, sensation, and erectile function were normal after treatment with no scar. CONCLUSION: Continuous traction with self-made adjustable tractor is a good method for all the types of inverted nipple. It is a simple, safe, effective, and minimally invasive method without scar.

Congenital amastia.

A 3-d-old female baby presented with bilateral congenital absence of breast tissue, areolae and nipples. No other anomalies were noted. There was also a history of absence of nipples, areolae and breast tissue in the mother and two other family members of maternal side. Investigations done during the hospital stay including ultrasound of the chest wall, abdomen and head were all normal. Congenital isolated bilateral amastia was diagnosed after complete investigations.

Congenital symmastia revisited.

BACKGROUND: Symmastia is defined as medial confluence of the breast. The term 'symmastia' is modified from Greek (syn meaning 'together', and mastos meaning 'breast') and was first presented by Spence et al. in 1983. Two forms of symmastia exist: an iatrogenic and a congenital version. Congenital symmastia is a rare condition in which web-like soft tissue traverses the sternum to connect the breasts medially. The literature on congenital symmastia is limited, few cases have been published, and knowledge about ideal treatment is still insufficient. MATERIAL AND METHODS: Congenital symmastia was identified as a distinct deformation using a review of the literature and a theoretical model. We analysed the malady using a three-step principle, formulated by Blondeel, which describes the breast as a 'footprint', 'conus' and 'skin-envelope'. To date, few papers on congenital symmastia have been published, most of which focus on the application of various surgical approaches. We examined the literature and evaluated the procedures used, and are presenting two recent cases of congenital symmastia as examples. By combining review and analysis we offer a rational treatment practice. RESULTS: The analysis showed that the optimal treatment begins by correcting the 'footprint', removing the excess 'conus' over the sternum, and finally reattaching the 'skin-envelope' to the sternum to recreate the normal medial border of the 'footprint'. Thus far, the two most common approaches used to treat congenital symmastia are: reduction mammaplasty and liposuction. CONCLUSION: By combining the Blondeel analysis with a procedural review, we developed a flow chart to offer a possible treatment practice.

Congenital abnormalities of the breast.

Congenital abnormalities of the breast and chest wall are seen frequently in breast, pediatric and plastic surgery clinics. Management involves a multidisciplinary team approach. The treatment for many of these conditions includes surgical correction. If the child is still growing, treatment timing is crucial and many of the surgical corrective procedures require more than one operation over a number of years. Although these deformities have less impact on functional capacity, the psychological consequences can be serious in adolescent patients. They can experience embarrassment, social isolation and complexities during sexual development, and this results in problems with relationships. The aim of this article is to spread awareness among the medical community of this range of conditions, so appropriate referrals are made and their impact is reduced by timely appropriate surgical intervention if appropriate.

Congenital smooth muscle hamartoma of the nipple: a case report.

BACKGROUND: Hamartoma is a benign developmental disorder. This focal malformation is composed of mature tissues normally observed in a given organ but randomly distributed, often in disturbed quantitative ratio, with growth rate similar to that of the surrounding tissues. Congenital smooth muscle hamartoma presents as flesh-colored or variably pigmented plaque or macule. To our knowledge this is the first case of congenital smooth muscle hamartoma of the nipple reported in the available literature. CASE: A 44-year-old woman with a history of left breast cancer, for which she had mastectomy and axillary node clearance in 2007, presented to the plastic surgery outpatient department to discuss the reconstructive surgery of the left breast and to evaluate her right hypertrophic nipple. After surgical excision of the right nipple-areola complex, histopathological result revealed a previously unreported lesion of the nipple. Diagnosis of congenital smooth muscle hamartoma of the nipple was made after literature review of the previously described cases of congenital smooth muscle hamartoma. CONCLUSION: Congenital smooth muscle hamartoma of the nipple should be considered in the differential diagnosis of tumors of the nipple. Differentiating congenital smooth muscle hamartoma of the nipple from other types of nipple lesions avoids unnecessary excision of this benign condition.

Management of flat or inverted nipples with simple rubber bands.

BACKGROUND: Occurrences of flat or inverted nipples are not uncommon problems, and although they should not preclude breastfeeding, they often seriously hamper initiation and continuation of breastfeeding. Various therapies including nipple exercise, breast shells, inverted syringes, or surgical corrections have been reported with varying success rates. SUBJECTS AND METHODS: A new method has been devised by the authors that consisted of tying a rubber band around the base of the nipple, with the help of a syringe applicator, to make it prominent. Latex rubber bands cut from condom rims were used in this study. The band had to be worn only during feeding. This method was tested on 19 mothers with flat, inverted, or otherwise deformed nipples. The babies were born in hospitals and were between 9 and 38 days old, mostly fed by bottle feeding, at the time of presentation. The mothers had been counseled about the importance of good attachment during breastfeeding and shown the new method. They were instructed to use the method at home and attend follow-up on day 3, day 7, and day 28. RESULTS: Sixty-three percent of mothers could achieve latching at the breast with good attachment within 3 days, and all did by the end of the month, as nipples no longer remained a problem. The insufficiency of milk was gradually taken care of by frequent suckling with time. No complications like pain or slipping of the band were reported. CONCLUSIONS: This simple method may be a good bedside solution for flat/retracted nipples. The authors strongly believe that if the new method is applied immediately after birth under supervision, no mother with nipple problem will be required to feed nonhuman milk to her baby.

Breast asymmetry during adolescence: physiologic and non-physiologic causes.

BACKGROUND: Pathologic breast conditions are rare in childhood and adolescence. The spectrum of breast disease in the pediatric age group is different from that in adults, and most lesions are benign. OBJECTIVES: To describe the causes and characteristics of breast asymmetry in adolescents with normal endocrine profiles and sexual development. METHODS: The files of patients with a diagnosis of breast asymmetry referred to a tertiary pediatric center from 1990 to 2007 were reviewed for history and findings on physical examination with or without imaging, treatment and outcome. RESULTS: Eleven patients aged 12.5 to 18 years were identified. The cause of the breast asymmetry was traced to unpreventable medical factors in eight patients (physiologic, Poland anomaly, scleroderma), preventable/iatrogenic factors in two patients (chest tissue biopsy, thoracic drain), and possible combined medical-iatrogenic factors in one patient (scoliosis treated with a body brace). All patients were referred for breast reconstruction after full breast development. CONCLUSIONS: Severe breast asymmetry in adolescence may be due to congenital factors, diseases involving the breast tissue, or to the effects of medical treatment, and may have severe adverse psychological and social implications. To prevent iatrogenic breast asymmetry, physicians should be made aware of the sensitivity of the breast tissue and should avoid unnecessary tests/procedures that involve the chest wall. In most cases a precise medical history and physical examination can differentiate between physiologic and non-physiologic causes.