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Postchemotherapy histiocyte-rich pseudotumor is a rare event in lymphoma patients and can cause elevated metabolic activity on positron emission tomography-computed tomography scan mimicking residual tumor. Here, we reported 11 lymphoma cases showing mass-like lesions with increased fluorodeoxyglucose uptake after chemotherapy. These postchemotherapy lesions occurred in various anatomic sites including spleen, mediastinum, lymph node, and other tissue locations, concerning for refractory or residual lymphoma. Their median size was 2.7 cm (range, 1.4 to 7.7 cm) and the median standardized uptake value on positron emission tomography-computed tomography was 10.6 (range, 5.2 to 13.8). Histologic examination of these lesions demonstrated reactive changes mainly composed of histiocyte-rich proliferation without viable lymphoma. Fat necrosis, cholesterol cleft, and calcium deposit were also commonly observed. After biopsies, 3 patients received additional chemotherapy, 2 had stem cell transplant with adjuvant chemotherapy or radiation, 1 had surgical excision, and the remaining 5 patients did not receive any further treatment. Follow-up imaging studies showed the resolved or decreased fluorodeoxyglucose activities in all patients including those without additional treatments, consistent with benign/reactive nature of these pseudotumor lesions. This study illustrates postchemotherapy mass-like lesions with elevated metabolic activity do not always represent residual disease and provides awareness of correlation between radiologic and histologic features of these lesions to avoid misinterpretation and overtreatment of lymphoma patients after chemotherapy.

Body mass index (BMI) has long been the proxy for patient selection in obese patients presenting for abdominally based breast reconstruction. BMI, however, fails to accurately reflect the distribution of abdominal adipose tissue. This study aims to quantify the effect of abdominal wall thickness on the incidence of post-operative complications and contrast abdominal wall thickness and BMI as predictors of post-operative morbidity.We performed a retrospective review of 106 consecutive patients who underwent abdominally based breast reconstruction. Abdominal wall thickness was quantified using preoperative CT angiograms. Primary outcomes included delayed wound healing (abdomen and/or breast), flap fat necrosis, return to OR in 30 days, infection, and flap loss.Patients experiencing delayed abdominal wound healing (n=38), delayed breast wound healing (n=27), and flap fat necrosis (n=24) had significantly thicker abdominal wall measurements (p0.0015). Of the 24 patients with palpable fat necrosis, 11 required excision. Increasing abdominal wall thickness significantly increased the odds of delayed abdominal wound healing (p=0.0005), delayed breast wound healing (p=0.0009), flap fat necrosis (p=0.0028), and infection (p=0.0198). Compared to BMI, abdominal wall thickness proved to be a more accurate predictor of delayed breast wound healing, any delayed wound healing, flap fat necrosis, and infection.Our data indicate that as abdominal wall thickness increases, so does the risk of postoperative morbidity. Abdominal wall thickness outperformed BMI as a predictor of postoperative morbidity in several areas. This suggests that objective data obtained from preoperative CT scans may allow more accurate, individualized perioperative risk assessment.

We report a case of an encapsulated fat necrosis without significant medical history. To differentiate from liposarcoma, it should be recognized that a half of abdominal encapsulated fat necrosis cases have a history of inflammation and surgery.

To explore the optimal type of breast reconstruction and the time interval to postmastectomy radiotherapy (PMRT) associated with lower complications in breast cancer patients receiving neoadjuvant chemotherapy. We reviewed the medical records of 300 patients who received neoadjuvant chemotherapy, mastectomy with breast reconstruction and PMRT at our institution from 2000 to 2017. Reconstruction types included autologous flaps (AR), single-stage-direct-to-implant and two-stages expander/implant (TE/I). The primary endpoint was the rate of reconstruction complications including infection, skin and fat necrosis. Subgroup analysis compared rates of capsular contracture, implant rupture, implant exposure and overall implant failure in single-stage-direct-to-implant to TE/I. The secondary endpoint was identifying the time interval between surgery with immediate implant-based reconstruction and PMRT associated with lower probability of implant failure. Logistic regression models, Kaplan–Meier estimates and Polynomial regression were used to assess endpoints. The median follow-up was 43.5 months. 29.3%, 28.3% and 42.4% of the cohort had AR, TE/I and single-stage-direct-to-implant D, respectively. The 5-year cumulative incidence rate of complications was 14.0%, 29.7% and 19.4% for AR, TE/I and single-stage-direct-to-implant, respectively (Log rank p = 0.02). Multivariate analysis showed significant association between TE/I and higher risk of infection (OR 8.1, p = 0.009) compared to AR, while single-stage-direct-to-implant and AR were comparable (OR 3.2, p = 0.2). On subgroup analysis, TE/I was significantly associated with higher rates of implant failure. The mean wait time to deliver PMRT after immediate reconstruction with no adjuvant chemotherapy was 8.4 and 10.7 weeks in single-stage-direct-to-implant and TE/I, respectively (p

Background The central mound technique offers a relatively less common approach for breast reduction. This study evaluated the expected safety and efficacy outcomes using this technique in a large patient series. Methods A retrospective review of all patients undergoing central mound breast reduction at the authors' institution between June of 1999 and November of 2018 was performed. Both bilateral macromastia and unilateral symmetrizing reduction patients were included but evaluated separately for some outcomes. Patient demographics and comorbidities, operative details, postoperative adverse events, and BREAST-Q scores were recorded. Associations between preoperative variables and outcomes were assessed with chi-square tests, Wilcoxon tests, and Kendall tau-b correlations. Results A total of 325 patients were identified for inclusion (227 bilateral and 98 unilateral; 552 breasts). The average patient age was 46 years, and the average body mass index was 27.4 kg/m. Among the bilateral macromastia patients, the average operative time was 3 hours 34 minutes, and average breast tissue removed was 533 g (right breast) and 560 g (left breast). Among all patients, average follow-up was 169 days. On a per-breast basis for all patients, the following complication rates were observed: seroma, 0.2 percent; hematoma, 1.1 percent; dehiscence, 2.9 percent; infection, 1.5 percent; hypertrophic scar, 4.6 percent; nipple necrosis, 0.4 percent; fat necrosis, 0.9 percent; and skin flap necrosis, 1.7 percent. Using the BREAST-Q Reduction/Mastopexy questions on a Likert scale ranging from 1 to 5, restricted to the bilateral macromastia patient population, all scores improved with statistical significance. Conclusion The central mound pedicle is a safe and effective approach for reduction mammaplasty for both bilateral macromastia patients and unilateral symmetrizing operations. Clinical question/level of evidence Therapeutic, IV.

In this article, we report a very rare case of secondary angiosarcoma in a young woman with no prior history of breast cancer who had bilateral prophylactic mastectomies with autologous reconstruction due to a strong family history of breast cancer and BRCA1 gene variant of uncertain significance. The surgery was complicated by recurrent fat necrosis requiring several excisions and additional reconstruction followed by the development of localized lymphedema and subsequent angiosarcoma in the reconstructed breast 10 years later. The angiosarcoma was high grade with prominent epithelioid features associated with abundant tumor-infiltrating lymphocytes. Amplification of C-MYC locus 8q21.24 was demonstrated by fluorescence in situ hybridization study. We postulate that chronic trauma from several surgeries including tissue hypoxia and impaired lymphatic drainage may have provided a milieu for angiogenesis and mutagenic transformation. Amplification of C-MYC locus 8q21.24 was most likely a strong oncogenic driver of angiosarcoma. To the best of our knowledge, this is the first report of its kind in the literature.

Summary Background The pedicled transverse rectus abdominis myocutaneous flap (TRAM) remains an effective and widely-used method for breast reconstruction despite well-documented donor-site morbidity. We present the island-type pedicled TRAM flap as a way to obtain better and more reliable outcomes in breast reconstruction. Methods A retrospective chart review of patients who underwent breast reconstruction with an island-type pedicled TRAM flap was performed. Patient demographics and complications were reviewed. In the island-type pedicled TRAM flap, we transversely resected the upper ipsilateral rectus muscle surrounding the origin of the superior epigastric vessels, preserving only a 1-cm muscle strip including the vascular pedicle to prevent epigastric bulging and inframammary fold (IMF) disruption. The flap was turned over into the ipsilateral breast pocket. The IMF was repaired except for the portion where the pedicle was placed. Results From January 2013 to November 2017, 88 patients underwent surgery using the island-type pedicled TRAM flap. The etiology of the defect was breast cancer with mastectomy in 86 cases, and paraffinoma in two cases. Seventy-seven patients underwent unilateral reconstruction, and 11 patients underwent bilateral reconstruction. Minor fat necrosis occurred in eight cases. Mild inframammary or epigastric bulging was observed in five cases, and neither partial nor total flap necrosis was observed. The aesthetic outcome of the IMF was evaluated in 55 cases, and 53 cases received good overall scores. Conclusion Although the island-type pedicled TRAM flap is technically challenging because careful dissection and pedicle identification is required, it can provide more reliable and better aesthetic results without an increased risk of vascular compromise.

Introduction Numerous techniques have been proposed for the plastic surgical treatment of hypertrophic breasts. Challenges of the procedure include the preservation of vascular supply and sensitivity of the nipple areola complex (NAC), breast feeding, and an esthetically pleasing result. Objectives In the present preliminary report, we introduce a new technique called the three-block L -wing reduction mammaplasty that addresses the aforementioned difficulties. Materials and Methods The three-block L-wing reduction mammaplasty with a thick hemispheric superiorly based NAC pedicle and a medial as well as lateral pillar was performed in a total of 60 patients. Results Our technique increases both, vascular safety and the sensory supply to the NAC, as it conceptually decreases the need for dissection of breast tissue and skin. The incidence of fat necrosis and wound healing disorders may be reduced with this technique. Because the ducts of the breast-gland underneath the NAC are not dissected, this technique also promises a higher probability of regular breast-feeding. Finally, our technique permits a cosmetically pleasing round-shaped mound of the breast. Conclusion The three-block modification simplifies the procedure of the superior pedicle L-wing mammaplasty markedly. It may increase the esthetic as well as the functional outcome and decrease postoperative complications.

Fat necrosis is a common complication for the deep inferior epigastric perforator (DIEP) flap. A thorough understanding of the factors associated with fat necrosis will aid operative planning for reconstructive surgeons. A systematic review of the literature was performed between January 1989 and April 2019. Studies were included if they reported on fat necrosis in DIEP flap or evaluated the perfusion of the DIEP flap. Twenty-eight out of 312 studies met the inclusion and exclusion criteria. Fat necrosis rates ranged from 12.0 to 45.0% on clinical examination within the literature. The four main perforator-specific factors identified included perforator perfusion zones, perforator location, perforator number and venous congestion. Medial row perforators have a wider perfusion zone, while lateral row perforators have a narrow perfusion zone. Holm zone III has a higher rate of fat necrosis compared to Holm zone II. One to two perforators and more than five perforators and a Type III atypical connection between the superficial and deep venous system had a higher rate of fat necrosis. The DIEP flap should incorporate between two and three perforators of a substantial calibre; Holm zone III should be excluded if able and careful review of the pre-operative imaging should be performed to analyse the connections between the deep and superficial venous system. There are multiple perfusion-related factors to consider when planning the DIEP flap and ultimately a patient-specific approach to the vascular anatomy is essential. 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 .

Background The use of tissue oximetry for monitoring following free tissue transfer has become a common practice across the United States to facilitate early detection of poor flap perfusion in the postoperative setting. There is no consensus on the optimal value, below which there is a higher chance of wound complications in patients undergoing free flap breast reconstruction. Methods Patients undergoing free flap breast reconstruction from 2015 to 2018 were retrospectively reviewed. Patients who returned to the operating room for a revision of the anastomosis were excluded from analysis. Patients were divided in two groups based on the development of late complications. Those were defined as fat necrosis, wound dehiscence, or distal flap ischemia/necrosis that developed after discharge from the hospital. Mean percutaneous oximetry readings of the first 24 hours were recorded and the mean change from the initial reading was calculated. The correlation between tissue oximetry change and development of complications was explored. Results A total of 120 patients were identified. The mean age was 53, while the mean body mass index was 33. A total of 38 patients developed late wound complication. History of smoking, diabetes mellitus, neoadjuvant radiation therapy, and the mean change of the tissue oximetry reading were identified as independent predictors of wound complications. The absolute number of the tissue oximetry reading did not predict late complications. A multivariate analysis revealed that patients who experienced a mean decrease Conclusion In patients undergoing free tissue breast reconstruction, tissue oximetry readings do not predict late wound complications. However, the mean change at 24 hours from the initial reading does. A decrease of

A 5‐year‐old male neutered domestic shorthair cat suffered from recurrent solitary nodules in different subcutaneous body regions. Nodules were surgically removed and each time histopathological diagnosis was fat necrosis and fibrosing to pyogranulomatous panniculitis. After the second surgery the alpha (α)‐tocopherol concentration in serum of the cat was examined and the result (21 mg/L) exceeded the upper limit of the reference interval (3–11 mg/L). Vitamin E amount in diet fed solely in the past was checked as studies have shown that vitamin E amounts in food significantly influence vitamin E concentrations in serum. For comparative purposes, α‐tocopherol concentrations were determined in sera of healthy control cats. Additionally, vitamin E amount in wet food from different manufacturers was analysed using gas chromatography coupled to mass spectrometry (GC‐MS). The results showed that the diet did not have higher vitamin E amounts compared to other diets. All control cats had similar high serum α‐tocopherol concentrations. We conclude that panniculitis can occur despite high serum α‐tocopherol concentrations in cats. Further studies are needed to redefine reference values of α‐tocopherol in serum of cats., To the best of our knowledge, this is the first case report of panniculitis in a cat despite its high serum alpha (α)‐tocopherol concentration. Our findings suggest that high serum α‐tocopherol concentrations may not always be protective against pathological disorders including panniculitis.

Here we present a novel method of breast reconstruction, a skin-sparing, wise pattern, internal mammary perforator (SWIM) flap. The nipple-sparing mastectomy is completed as per the oncological standard. Reconstruction is then performed, using only local flaps to create a breast. The nipple is carried on a medial flap that is based on the internal mammary perforators. A lateral intercostal artery perforator (LICAP) flap can also be utilized for additional volume. There is no implant or anastomosis required and no muscle is sacrificed. Incisions are closed based on a classic Wise pattern. Seven patients underwent bilateral SWIM flaps for a total of fourteen breasts, with minimal complications limited to minor wound healing and one case of operative fat necrosis. All patients were satisfied with their results, with two patients desiring larger breast size and undergoing fat grafting at a secondary surgery.

Summary Introduction Abdominoplasty is a popular aesthetic operation. Complication rates vary from 4–80%. To date, there is a lack of evidence for complication-reducing techniques. The aim of this meta-analysis was to summarise and quantify the effects of these techniques on complication rates and determine the safest combination. Methods A literature search was undertaken from MEDLINE, EMBASE, and Cochrane Central Register of Controlled Trials databases. Two authors assessed the abstracts and evaluated their suitability for inclusion in the review. For each complication (including overall), a random effects meta-analysis was conducted to investigate the average number of complications. The log rate and associated variance is calculated in R using the “escalc” function from the metafor R package. For the forest plots the model output is back-transformed to the original scale. Results 4295 patients were included in the meta-analysis. Overall complication rates ranged from 9.3–33.8%. Revision rates were 3–21.9%. Forest plots of data extracted from observational studies demonstrated summary measures favouring the sub-scarpal fat preservation and drains, and drains only groups for overall complications. There were no significant differences between groups for seroma, haematoma, infection/abscess, skin/fat necrosis, dehiscence, surgical revision rate and VTE rate. Conclusions The rates of individual complications are no different with or without the use of PTS, drain or sub-Scarpal fat preservation in different combinations.

Background and objectives To report on the outcomes and evolution of an oncoplastic mammaplasty referred to as geometric compensation mammaplasty. Methods Seventy-three patients with malignant tumours were operated on and followed up in five centres in two countries. Preoperative markings were performed using a Wise pattern. The resection of affected skin was geometrically compensated using another area of preserved skin. Results Mean pathological tumour size was 30.42 ± 21.98 mm. Twenty tumours (30.77%) were locally advanced and 15 (20.55%) were multicentric. Twenty-two patients (34.38%) were submitted to neoadjuvant chemotherapy. Cosmetic results were considered good or excellent in 59 cases (80.82%). Margins were positive in two cases (2.74%). Complications were partial wound dehiscence (n = 11; 15.07%), fat necrosis (n = 9; 12.33%), skin necrosis (n = 5; 6.85%), seromas (n = 5; 6.85%), enlarged scars (n = 7; 9.59%) and infection (n = 2; 2.74%). There were three cases of local recurrence (4.29%), two of bone metastasis (2.86%) and three of metachronous contralateral breast cancer (4.35%). No deaths were recorded within a mean follow-up of 35.33 ± 28.21 months. Conclusions The technique allowed breast conservation in situations requiring a large resection of skin in difficult positions, with a high rate of free margins, correction of ptosis, satisfactory symmetry and few complications.

Background Fat grafting has been widely used for facial rejuvenation and soft tissue reconstruction. However, it is associated with a lower retention rate than expected and complications such as fat necrosis or calcification. Several techniques that may increase the survival rate of fat grafts have been proposed. The techniques that promote the recipient sites vascularity to increase the survival rate of fat grafts include administration of growth factors, platelet- rich plasma, and adipose derived-stem cells or preconditioning of the recipient fat graft site. Methods In this study, the authors evaluated the effect of hyaluronidase on autologous fat graft survival by pretreatment with hyaluronidase at the recipient site by using an animal model. In the experimental group, the recipient site of the fat graft was pretreated with hyaluronidase before fat grafting, whereas the control group was pretreated with normal saline. Results After 8 weeks of fat grafting, the average volume retention was 78.2% in the experimental group and 68.6% in control group. Considerable fibrosis between the fat globules in the control group was confirmed with Masson trichrome staining. CD31 immunofluorescence staining was performed and stained vessels were counted. Counted vessel number was significantly greater in the experimental group than in the control group. Conclusions Pretreatment of hyaluronidase on the fat graft recipient site is a good option to enhance the outcome of the fat graft in the clinical setting.

Optimizing esthetics in delayed breast reconstruction is a challenge, as there is a lack of breast volume and native breast skin. Abdominal flaps are commonly used for patients desiring autologous reconstruction, but the result is an unnatural appearing breast as non-breast skin is used to recreate the breast mound. To improve esthetics for these patients, we propose a two-staged approach utilizing prepectoral tissue expander placement. A retrospective analysis of all patients undergoing delayed breast reconstruction with prepectoral tissue expander placement at our single tertiary-care institution was performed. We collected demographics, complication rates, and surgical information from both the first and second stage surgeries for all patients. Charts were further reviewed to determine whether patients pursued revisions. Five patients (eight breasts) met inclusion criteria. Following tissue expander placement, there was one incidence of seroma (n = 1), and no other complication occurred. Complications after autologous reconstruction included donor-site hematoma (n = 1), recipient-site dehiscence (n = 1), and recipient-site fat necrosis (n = 1). No flap losses or other complications occurred for our series of patients. Delayed, two-staged autologous breast reconstruction requires an additional short, surgical procedure that results in a lifelong improved breast esthetic and better lower-pole ptosis. Complication rates remain low, which makes this a viable and safe option to improve outcomes for patients seeking delayed autologous reconstruction. Our study utilizes prepectoral expander placement, which we believe will further enhance the quality of patient care. Level of evidence: Level V, therapeutic study.

Background This study aims to characterize the effect of laser-assisted indocyanine green fluorescence angiography on fat necrosis and flap failure in deep inferior epigastric artery perforator (DIEP) flap breast reconstruction. Methods A retrospective review was performed on 1000 free flaps for breast reconstruction at a single center from 2010 to 2017. Indocyanine green angiography was used after completion of recipient-site anastomoses to subjectively assess for areas of hypoperfusion. A multivariable logistical analysis was conducted with 24 demographic and surgical factors and their effects on fat necrosis and flap failure. Results Five hundred six DIEP flaps were included in the statistical analyses. Thirteen percent of flaps had fat necrosis. Indocyanine green angiography was used for 200 flaps and was independently associated with a decrease in the odds of fat necrosis (OR, 0.38; p = 0.004). There was no reduction in flap failure rates when using indocyanine green angiography (OR, 1.15; p = 0.85). However, there was a decrease in flap loss with increasing venous coupler diameter (OR, 0.031 per 1-mm increase; p = 0.012). The 84.9-g higher weight of resected tissue before inset without indocyanine green angiography versus the weight of the tissue resected with indocyanine green angiography was statistically significant (p = 0.01). Per single incident of fat necrosis, our cohort underwent an additional 0.69 revision procedures, 1.22 imaging studies, 0.77 biopsies, and 1.7 additional oncologic office visits. Conclusion Intraoperative indocyanine green fluorescence angiography decreases the odds of fat necrosis, saves volume when flap trimming at inset, and can significantly reduce the postoperative surveillance burden in DIEP-based breast reconstruction. Clinical question/level of evidence Therapeutic, III.

A variety of free tissue flaps have been described for autologous breast reconstruction. Although the deep inferior epigastric perforator (DIEP) flap is most microsurgeons’ first choice, there is no consensus regarding which is the second-best alternative. The transverse upper gracilis (TUG) flap has gained popularity for cases where the abdomen is not a suitable donor site. This musculocutaneous flap has the advantage of an easy dissection, allowing the harvest of tissue from the medial thigh area with the patient supine. However, drawbacks include a tedious donor site closure and a limited amount of soft tissue that can be transferred. The authors hereby present a modification of the TUG flap, introducing an L-shaped skin paddle: the L-shaped upper gracilis (LUG) flap. This alternative allows harvesting extra tissue from the medial thigh, while providing an easier donor site closure with the patient supine. A prospective case series of 14 LUG flaps is presented. No flap failures or episodes of fat necrosis were encountered; only one developed a donor site seroma that settled after drainage. The LUG flap is a useful development of the TUG flap concept providing up to 50% more tissue than a standard TUG flap with an aesthetically pleasing donor site closure which is useful for cases in which abdominal flaps are not possible.Level of evidence: Level IV, therapeutic study.

Background Breast hypertrophy is a condition of abnormal enlargement of the breast which may continue until each breast weighs more than 1.5 kg (macromastia) or even more than 2 kg (gigantomastia). Supporting such heavy weights leads to cervical and upper thoracic back pain, costochondritis, and fungal infections in the mammary folds, making reduction mammoplasty essential. However, there is a lack of consensus among plastic surgeons as to the best technique. This study reports the results of reduction mammoplasties in South African women using the Wise pattern, minimally undermined with a medial pedicle. Methods A retrospective record review of the reduction mammoplasties was conducted over a 1-year period. Patient records were assessed for early complications related to vascular reliability. Results One hundred and fourteen Wise pattern minimally undermined, medial pedicle techniques were performed on 57 consecutive patients in the 1-year period at the NetCare Rand Clinic in Berea, Johannesburg, South Africa (EN). The patients' sternal notch to nipple distances ranged from 28 to 52 cm. The volume of breast reduction ranged from 345 g to 3300 g per breast. The overall complication rate was 9.7%, consisting of fat necrosis (3.5%), infection (1.7%), dehiscence (3.5%), and nipple epidermolysis (0.9%). Conclusion The minimally undermined Wise pattern medial pedicle breast reduction technique proved to be a reliable technique for breast reduction in the South African population. Safety in pedicle breast reduction with sternal notch to nipple distances of up to 50 cm, as well as reliability and versatility in a wide range of breast sizes, was demonstrated.

Highlights • Epiploic Appendages are mobile, pedunculated pouches. • It’s a self-limited condition that could occur due to torsion or thrombosis of its vessels. • The Patient’s complaint may be subacute lower abdominal pain, left-sided in in most cases. • Early recognition of this condition is crucial to avoid an operation when unnecessary leading to prolonged hospital stays., Introduction Epilopic appendagitis (EA) is an uncommon condition of abdominal pain caused by the local inflammation of the fat-filled peritoneal outpouchings due to torsion or thrombosis of its vessels leads to ischemia and gangrenous necrosis of the aappendages, as it can cause peritoneal irritation, acute ischemia, and fat necrosis. Case report We present a case of epilopic appendagitis mimicking appendicitis of a 10 years old male, presented to the emergency department with severe right quadrant pain pointedly at the right lumbar area. Associated with constipation and nausea for once. Computed tomography (CT) scan with contrast was performed showing an ovoid fat structure with thin enhancing rim and surrounding inflammatory stranding as well as prominent lymph nodes at hepatic flexure, free fluid and no evidence of appendicitis. The patient was discharged with pain control medications. Discussion Epiploic Appendages are mobile, pedunculated peritoneal out pouches. Considering its mobility and narrow pedicle appendages are disposed to torsion leading to appendagitis causing local inflammation, peritoneal irritation, acute ischemia, and fat necrosis. The patient’s main complaint would be a subacute lower abdominal pain, left-sided in 60–80% of cases. Conclusion Early recognition of this condition is crucial to avoid an operation when unnecessary leading to prolonged hospital stays. The management is conservative with analgesic.

BACKGROUND Seroma is a common complication after breast surgery such as mastectomy and immediate reconstruction. However, there is a lack of evidence for the utility of drains in the recipient site in delayed autologous breast reconstruction. We reviewed our experience with delayed abdominal-based flap breast reconstruction with a drainless recipient site. METHODS A single-surgeon retrospective case review was performed for delayed abdominal-based flap breast reconstruction using drainless recipient sites from May 2018 to June 2019. Primary outcomes were recipient-site complications. RESULTS Thirty-one delayed abdominal-based flap breast reconstructions that did not use drains in the recipient site were identified in 22 patients. Mean age was 52.8 years (SD, 9.7 years). Mean body mass index was 30.1 kg/m (interquartile range [IQR], 28.2-35.0 kg/m). Common comorbidities were obesity (45.4%), prior tobacco use (31.8%), and diabetes (10.0%). Median time to abdominal-based flap reconstruction was 27.5 months (IQR, 9.9-105.2 months). There were 22 muscle-sparing transverse rectus abdominis musculocutaneous flaps and 9 deep inferior epigastric artery perforator flaps performed. Ten patients (45.4%) underwent bilateral reconstruction. Mean operative time was 302 minutes (SD, 85 minutes). Flap take back occurred in 1 case (3.2%). Mean length of stay was 4 days (SD, 0.8 days). Recipient-site complications were healing complications (32.3%), seroma (3.2%), hematoma (3.2%), and fat necrosis (19.4%). Median follow-up was 4.2 months (IQR, 2.5-11.5). CONCLUSIONS In this case series, our data indicate that delayed autologous reconstruction without drain placement at the recipient site has been proven to be safe and successful and did not increase the rate of seroma or other complications. Adopting a drainless approach may also improve patient comfort and satisfaction.

Purpose To compare single-stage direct-to-implant (DTI) immediate reconstruction to the commonly used 2-stages expander and implant (TE/I) or autologous reconstruction with focus on postmastectomy radiation therapy (PMRT) setting. Methods and Materials We reviewed the charts of 1,286 patients who underwent 1,814 breast reconstructions at our institution with and without PMRT from 1997 to 2017. Patients were divided into 6 groups according to type of reconstruction and PMRT status. Primary objective was reconstruction complications defined solely on surgical reintervention operative notes such as infection, skin necrosis, and fat necrosis across all groups. Implant-related complications such as capsular contracture, implant rupture or exposure, or implant failure were compared between TE/I and DTI. Kaplan–Meier estimates were used to calculate 5-year cumulative incidence of complications. The secondary objective was to compare the 3 reconstruction types in settings of immediate reconstruction followed by PMRT on multivariable analysis. Results Median follow-up was 5.8 years. Among 1286 patients, 41.1% (N = 529/1286) received PMRT. Among 1814 reconstructed breasts, autologous, single-stage, and TE/I represented 18.7%, 34.8%, and 46.2%, respectively. With no PMRT, the 5-year cumulative incidence of any reconstruction complication was 11.1%, 12.6%, and 19.5% for autologous, DTI, and TE/I reconstructions, respectively. The addition of PMRT resulted in 5-year cumulative incidence of 15.1%, 18.2%, and 36.8%, respectively. The multivariable analysis showed that DTI was associated with lesser complications compared with TE/I, whereas no significant difference was noted between DTI and autologous. Conclusions Single-stage DTI reconstruction had significantly lower complication rates than TE/I with and without PMRT. Single-stage complication rates were not significantly different from autologous complication rates in PMRT settings. Single-stage reconstruction may offer a valuable option for patients receiving PMRT.

Breast augmentation with fat grafting is used as an alternative to breast implants. However, a systematic evaluation of the complication rates after fat grafting using only studies with consecutive patients has not previously been performed. In this study, the authors compiled studies reporting complication rates and radiologic changes in consecutive patients undergoing cosmetic breast augmentation with fat grafting.Studies reporting on consecutive patients undergoing breast augmentation with fat grafting were included. Complication rates, radiologic changes, Breast Imaging Reporting and Data System assessments, and the number of patients undergoing revision surgery were extracted. Mean complication rates and radiologic changes were calculated with meta-analytical methods.Twenty-two studies with 2073 patients were included. The rates of major complications were low (hematoma, 0.5 percent; infection, 0.6 percent; and seroma, 0.1 percent). None of these patients needed revision surgery. The most frequent minor complication was palpable cysts in 2.0 percent of the patients; 67 percent of these were treated with aspiration. The radiologic changes in the patients after fat grafting were as follows: oil cysts, 6.5 percent; calcifications, 4.5 percent; and fat necrosis, 1.2 percent. The risk of being referred for additional radiologic imaging (e.g., to exclude malignant changes) was 16.4 percent, and the risk of being referred for biopsy was 3.2 percent.The complication rates after breast augmentation with fat grafting are low and support fat grafting as an alternative to breast augmentation with implants. The rates of radiologic changes are high after fat grafting, but the changes do not seem to have any therapeutic consequences for the patients.

Cryolipolysis has been marketed as a safe and effective alternative to invasive procedures for reduction of subcutaneous fat and body contouring. Some complications include erythema and paradoxical adipose hyperplasia. We present a case report of bilateral flank lumps post 2 sessions of cryolipolysis. Literature search was performed for “Cool sculpting” AND “adverse effects” OR “Side effects” OR “Complications” OR “cryolipolysis” AND “Fat necrosis”. Histopathology slides were also reviewed by a senior consultant pathologist. The mechanism of action of each non-invasive fat reduction modality differs; cryolipolysis works by apoptosis, not necrosis. However, on review of the histopathology slides, necrosis was a predominant feature of the bilateral flank lumps that were excised. This is the first known publication of fat necrosis following cryolipolysis and while fat necrosis is incongruent with known complications, we propose that in persistent lumps following cryolipolysis, fat necrosis should be part of the differential. Level of evidence: Level V, risk/prognostic study.

Background Although many attempts have been made to augment the volume of the latissimus dorsi (LD) myocutaneous flap in breast reconstruction, only a few studies on the shaping of the LD flap to achieve a natural native breast have been conducted. We introduce our novel method to reconstruct a naturally shaped breast by combining an extended LD myocutaneous flap with immediate lipofilling. Methods The patients who underwent an immediate unilateral breast reconstruction with an extended LD myocutaneous flap and lipofilling were retrospectively reviewed. The extended LD myocutaneous flap in 180-degree rotation was combined with an immediate lipofilling procedure followed by suturing to reproduce the constant dimensions of a neobreast. Results A total of 45 patients with a mean age of 46 years and an average body mass index of 23.1 kg/m were enrolled. The average weight of the mastectomy specimens was 299.0 g. An average 18.8 × 8.7-cm skin paddle within the flap was harvested, and 71.0 mL of fat was injected into the flap. Donor site seroma was found in 9 patients, and no flap or fat necrosis was found. Conclusions Our technique of extended LD muscle flap with lipofilling reproduced breasts with constant dimensions and appropriate width, height, and projection. Shaping the LD muscle flap is not difficult or unpredictable. This is a simple and easy technique to shape the LD flap and will provide surgeons with an additional autologous option for breast reconstruction.

Background Some surgeons have advocated for the use of bipedicle-conjoined deep inferior epigastric perforator (DIEP) flaps in unilateral autologous breast reconstruction in thin patients in whom a hemiabdominal flap is deemed insufficient. There have been no studies to date, however, exploring complication rates for bipedicle-conjoined DIEP flaps for unilateral reconstruction in overweight or obese patients. Methods The authors performed a retrospective review of two senior authors' patients from 2013 until 2018. In this time period, 71 patients underwent unilateral breast reconstruction with bipedicle-conjoined DIEP flaps. The patients were divided into normal weight (body mass index [BMI] 25, n = 41) groups. Outcomes were reviewed for both major and minor complications. Results The average BMI of the normal group was 23.1 ± 1.3 kg/m2, while the average BMI of the overweight/obese group was 28.9 ± 4.0 kg/m2 (p There were no statistically significant differences in the overall incidence of major or minor complications between the two groups (major: overweight/obese = 12.1%, normal BMI = 10.0%, p = 0.39; minor: overweight/obese = 39.0%, normal BMI = 36.7%, p = 0.47). The rate of moderate fat necrosis was significantly higher in the overweight/obese group (overweight/obese = 9.8%, normal BMI = 0%, p = 0.04). Conclusion Unilateral breast reconstruction with bipedicle-conjoined DIEP flaps can be performed safely in overweight and obese patients. The use of bipedicle-conjoined DIEP flaps in this population allows surgeons to provide overweight or obese patients with reconstructions that are commensurate with their body habitus and/or contralateral breast.

Background/aim: Mesenteric panniculitis MP is an idiopathic benign disease characterized by fat necrosis, chronic inflammation, and fibrosis. The relationship between obesity and chronic low-grade inflammation has been reported. This study investigated the relationship of MP diagnosed using multidetector computed tomography MDCT with visceral adipose tissue VAT and subcutaneous adipose tissue SAT areas.Materials and methods: We retrospectively enrolled 104 patients with no radiological findings other than MP. Additionally, 76 individuals without any indicative radiological findings were included as controls. VAT and SAT were separately calculated cm2 using a 3-dimensional workstation. The abdominal circumference was measured cm . Results: The mean abdominal circumference was 99.9 ± 7.9 cm, SAT was 195.3 ± 89.1 cm2, and VAT was 203.9 ± 72.8 cm2 in the MP group. The abdominal circumference, VAT, and SAT were significantly higher in the MP group than in the control group P < 0.001 . According to the receiver operating characteristic ROC analysis, cut-off level VAT and SAT were 167.5 cm2 sensitivity 71%, specificity 69% and 117.5 cm2 sensitivity 78%, specificity 51 % , respectively.Conclusion: Increased VAT and SAT were associated with MP, suggesting their role in the etiology of MP.

Intra-abdominal fat is abundantly present in both the peritoneum and retroperitoneum. Fat necrosis or inflammation are common findings in abdominal imaging. The most common pathologies that we encounter are epiploic appendagitis, omental infarction, mesenteric panniculitis, and encapsulated fat necrosis. Less common entities that can occur are pancreatic saponification, heterotopic mesenteric ossification, and pseudolipoma of the capsule of Glisson. These entities can mimic more urgent pathologies such as appendicitis, diverticulitis, or malignancies.

Anisometric cell lipoma (ACL) and dysplastic lipoma (DL) are underrecognized subtypes of benign lipomatous tumors, with wide variation in cell size, microscopic fat necrosis, and no or mild nuclear changes (DL). ACL/DL appear more commonly in retinoblastoma patients, in whom an increased incidence of lipomas has been established. The occurrence of ACL/DL in retinoblastoma patients suggests that RB1 aberrations play a role in its pathogenesis, similar to spindle cell/pleomorphic lipoma. In this article, we present a patient with a history of retinoblastoma with multiple lipomas histologically consistent with ACL/DL. Analysis of the lipomas supports involvement of RB1 in the development of ACL/DL. Dysplastic changes were only seen in a single lipoma, which harbored an additional TP53 mutation. While providing further support for the occurrence of ACL/DL in retinoblastoma patients, we also suggest that DL is an ACL with TP53 mutation.

Introduction: Calciphylaxis is a condition which involves ectopic deposition of calcium in arterioles of various organ systems. Here, we present a rare case of mammographic calcifications in a patient on long-standing renal dialysis. Case: This is a 57-year-old female who presented to breast clinic with unilateral severe pain and lumpiness of her breast. On mammography, calcifications were identified which were associated with focal lesions on ultrasound. An image-guided core biopsy showed numerous foci of histological calcification within a large area of fat necrosis. The location within arterioles was confirmed by CD31 immunohistochemistry. The diagnosis of fat necrosis with benign calcifications due to mammary calciphylaxis was made. Conclusion: The hallmark of calciphylaxis is the deposition of calcium within small- to medium-sized vessel walls. This leads to ischaemia and necrosis of tissue. In the breast, only a few cases were reported in which patients presented with a necrotic lesion resembling carcinoma. These are reviewed in this report.

Summary Fat necrosis is a common complication after autologous breast reconstruction using a free flap, which can influence reconstruction outcome and patient satisfaction. Intraoperative near-infrared fluorescence imaging using indocyanine green permits visualization of flap perfusion. The aim of this study was to assess the effect of near-infrared fluorescence on fat necrosis incidence in patients undergoing an autologous breast reconstruction with a deep inferior epigastric perforator flap and to propose a standard working protocol for this technique. In this prospective study, patients undergoing one-sided autologous breast reconstruction with a deep inferior epigastric perforator flap were included. The standard deep inferior epigastric perforator flap procedure was complemented with near-infrared fluorescence imaging using the fluorescent tracer indocyanine green to evaluate flap perfusion. This cohort was compared to a retrospective cohort of deep inferior epigastric perforator flap procedures without near-infrared fluorescence imaging. Patients and surgery characteristics, as well as postoperative complications, were registered and compared. In both cohorts 24 patients were included. No significant differences were present between patients and surgery characteristics, including no difference in duration of surgery. In the prospective and retrospective group the incidence of fat necrosis was 4.2% and 33%, respectively (p-value = 0.023). Moreover, microsurgeons were positive about using near-infrared fluorescence as it either provided additional information about perfusion or confirmed clinical assessment. Our pilot study showed a significant decrease of fat necrosis in patients undergoing an autologous breast reconstruction with a deep inferior epigastric perforator flap when near-infrared fluorescence imaging was used to asses flap perfusion. This study provides a standardized working protocol for near-infrared fluorescence imaging. In future, large multicenter studies should focus on quantification of near-infrared fluorescence imaging.

Background Umbilical discharge in an adult is rare and generates broad diagnostic considerations. Umbilical anatomy is variable owing to congenital abnormalities and acquired pathology such as umbilical hernias. The umbilicus can be a site of primary or metastatic malignancy or endometriosis. Case presentation A 40-year-old white American woman came to the clinic with a 2-day history of spontaneous umbilical bleeding. She reported periumbilical pain associated with nausea and emesis. There were no visible skin abnormalities, but deep palpation of the abdomen produced a thin, watery, serosanguineous fluid from the umbilicus. She experienced a similar episode of umbilical bleeding 5 years prior without clear cause. Laboratory workup was notable for mildly elevated C-reactive protein . Computed tomography imaging revealed a fat-containing umbilical hernia with fat necrosis, necessitating complete surgical resection of the umbilicus. Conclusions Umbilical hernia with fat necrosis is a rare condition that should be considered in adults with umbilical discharge. Additional diagnostic considerations in adults with spontaneous umbilical bleeding/discharge include embryonal remnants, omphalitis, and metastasis. If the cause is not readily apparent on physical exam, imaging with computed tomography should be considered to assess for hernia and embryonal anomalies.

Patient: Female, 83-year-old Final Diagnosis: Sclerosing mesenteritis Symptoms: Abdominal pain • intestinal obstruction • vomiting Medication: — Clinical Procedure: — Specialty: Surgery Objective: Rare disease Background: The term “sclerosing mesenteritis” includes a spectrum of rare idiopathic diseases involving the small and/or large bowel. It appears as a diffuse, localized, or multinodular thickening of the mesentery, with a variable degree of chronic non-specific inflammation, fat necrosis, and fibrosis. Case Report: Here, we report a case of 83-year-old woman with symptoms of intestinal occlusion, vomiting, and abdominal pain. Radiographic examinations showed air fluid levels in right and left quadrants and in the mesogastric site, while computed tomography (CT) documented a strangulated inguinal hernia with ileal obstruction. Based on clinical examination and radiologic findings, the patient underwent surgery for inguinal hernia reduction. The examination of viscera revealed 2 tracts of ileum with ischemic signs and covered by fibrin; thus, the 2 intestinal loops were resected. Histological examination revealed chronic non-specific inflammation of the whole intestinal wall, including the subserosa in the resected tract of proximal ileum, while the distal ileal loop (not herniated tract) showed a subserosal fibrous nodule of 2 cm in greatest diameter, composed of a proliferation of spindle cells haphazardly arranged in a collagenized stroma. The diagnosis of sclerosing mesenteritis was rendered. Conclusions: The present case shows the possibility of an incidental diagnosis during another intervention such as hernia surgery. Pathologists should be aware of this disease to avoid confusion with aggressive tumors such as intra-abdominal desmoid-type fibromatosis and gastrointestinal stromal tumor.

SUMMARY One key component of a successful autologous breast reconstruction is insetting the flap to accurately resemble an aesthetic breast. The authors describe a novel technique used to shape a deep inferior epigastric artery perforator flap into a coned breast mound before introducing it into the breast pocket. With the flap perfusing on the chest wall, an area of skin estimating the size and location of the skin paddle is marked. The skin to be buried is then deepithelialized. Once hemostasis is ensured, the shaping is performed. Two 2-0 polydioxanone sutures are anchored in the Scarpa fascia at the 10- and 2-o'clock positions and then run at the level of the Scarpa fascia to the 6-o'clock position. The two sutures are then cinched together to achieve the desired shape and then tied. The flap is then placed in the breast pocket and secured into place at the inferomedial and inferolateral corners, and at its cranial aspect. The size of the skin paddle can then be finalized. In the authors' series of 21 breast reconstructions in 11 patients using flap preshaping, they have not seen any compromise in flap perfusion, with one patient showing a small area of secondary fat necrosis. In addition, the flaps maintained their aesthetic breast shape throughout follow-up. The authors believe this technique for shaping inferior epigastric artery perforator flaps before inset into the breast pocket to be both safe and predictable, simplifying one of the more tedious aspects of autologous breast reconstruction.

A boy weighing 4500 g was born at 41 weeks' gestation by Cesarean section due to fetal distress. The pregnancy was complicated by gestational diabetes. He had an Apgar score of 5 and 6 after 5 and 10 minutes, respectively. At birth, the newborn manifested respiratory distress, which needed assisted ventilation for 48 hours. He developed a convulsive attack, diagnosed as a grade 2 hypoxic-ischemic encephalopathy, which was controlled by phenobarbital. Four days later, dermatologic examination revealed subcutaneous and firm nodules, ranging from 1 to 4 cm in diameter, on the cheeks, neck, arms, legs, and back (Figure 1). Some nodules became fluctuant as abscesses. Fine-needle aspiration cytology performed on a nodule revealed a dirty background with necrotic fat-containing characteristic, radially- oriented, refractile, needle-shaped crystals (Figure 2), which was diagnosed as subcutaneous fat necrosis. The diagnosis of subcutaneous fat necrosis of the newborn was made. Laboratory studies revealed hypocalcemia at 1.65 mmol/L, hypomagnesemia at 0.48 mmol/L, and hypokalemia at 3 mmol/L. The infant received calcium, magnesium, vitamin D, and potassium supplementation. On day 18, the serum calcium increased to 3.3 mmol/L. It was associated with hypertriglyceridemia at 2.6 mmol/L. Bilateral nephrocalcinosis was detected on renal ultrasound. So, hyperhydration, diuretics, and withdrawal of vitamin D were indicated. The patient was given betamethasone 0.125 mg/kg/day for 3 weeks. After a two months course, there had been complete healing of the fat necrosis (Figure 3), normalization of the calcium and triglyceride levels, and a normal growth pattern.

Fat necrosis is an inflammatory process of fat folloing an insult to the adipose tissue. It is more common in the body region here there is high adipose tissue. It can present ith cellulitis, skin necrosis, discharging ounds, and mass. Carcinoma is one of the differential diagnoses of fat necrosis. Our case is presented ith a gluteal mass hich as diagnosed as a hydatid cyst, based on the imaging. Sometimes, imaging fails to identify traumatic fat necrosis, particularly if it is associated ith a capsule ith multiple fat lobules. Postoperative history confirms the encapsulated type of fat necrosis ith fat lobules. Encapsulated traumatic fat necrosis should be considered one of the differential diagnoses of hydatid cyst.