Surgical Treatment of Breast Lymphedema: A Distinct Pathology With Unique Challenges.

BACKGROUND: Supermicrosurgical advances such as lymphovenous bypass (LVB) have enabled effective physiologic treatment of lymphedema affecting the extremities. Reports of surgical treatment for breast lymphedema (BL) are sparse, consisting of case reports and almost exclusively LVB. We report our experience with BL, including a case of mastectomy and breast reconstruction with abdominal free flap and inguinal vascularized lymph node transfer (VLNT) for BL. We compare our series with the surgical literature to discern unique characteristics and treatment limitations inherent to this disease. METHODS: A database was prospectively maintained from September 2020 to May 2023 including all patients diagnosed with BL who were referred to our institution. Breast lymphedema was diagnosed using clinical criteria, and relevant patient data were recorded. Patients interested in surgical management underwent indocyanine green lymphography to determine candidacy for LVB or other interventions. All patients, including those surgically managed, were treated with complex decongestive therapy. RESULTS: Nine patients with BL were included. Eight had undergone breast-conserving therapy for breast cancer with whole breast irradiation. One patient was treated for Hodgkin lymphoma with axillary lymphadenectomy and axillary radiation. Indocyanine green lymphography was performed in 6 patients, of which 4 patients had diffuse dermal backflow. Two patients had lymphatic targets suitable for LVB, including the patient without breast irradiation. Three patients were managed surgically. One patient without bypass targets underwent breast reduction with partial symptomatic relief, later followed by a mastectomy with abdominal free flap reconstruction and VLNT. Two patients with suitable bypass targets underwent LVB, with resolution of breast swelling and subjective symptoms. CONCLUSIONS: The diffuse lymphatic obliteration due to radiation field effect in BL results in a distinct pathophysiology compared with extremity lymphedema. Although published reports of surgical BL treatment almost exclusively describe LVB, other surgical options may be more frequently required. Ablative strategies such as mastectomy and regenerative techniques such as VLNT should be considered potential first-line treatment options for these patients.

A devastating case of a Balamuthia mandrillaris pediatric brain infection.

Balamuthia mandrillaris is an amoeba that causes an uncommon but deadly encephalitis, referred to as granulomatous amoebic encephalitis (GAE). The highest incidence reported worldwide has occurred in America, and within the United States, it has been highest in the Southwest affecting predominantly children and young men of Hispanic ethnicity. Clinical presentation of GAE includes fever, headache, nausea, vomiting, lethargy, irritability, stiff neck, hallucinations, photophobia, and seizures. Our patient was a Hispanic male child living in Arizona. The patient presented at 3 years of age for severe encephalitis. Symptoms included difficulty with balance, gait, and sitting up and seizure-like activity. Initial CT showed an area of decreased density consistent with edema in the right frontal and left frontoparietal lobes. Rapid progression was seen on further imaging over the length of the patient's hospital stay revealing diffusion restriction, necrosis/blood products, edema, and hemorrhage. The patient expired three weeks after onset of symptoms and one week after admission to our institution. While there are multiple biochemical techniques that can test for B. mandrillaris, they are rarely employed for multiple reasons stemming from the rare occurrence of this infection. Because of the fatal nature of this infection, we propose (1) testing should be considered if a patient presents with progressing encephalitis on imaging and other pathogenic etiologies are ruled out and (2) the threshold to treat empirically should be low due to the fatal nature of the infection.

Sex classification of 3D skull images using deep neural networks.

Determining the fundamental characteristics that define a face as "feminine" or "masculine" has long fascinated anatomists and plastic surgeons, particularly those involved in aesthetic and gender-affirming surgery. Previous studies in this area have relied on manual measurements, comparative anatomy, and heuristic landmark-based feature extraction. In this study, we collected retrospectively at Cedars Sinai Medical Center (CSMC) a dataset of 98 skull samples, which is the first dataset of this kind of 3D medical imaging. We then evaluated the accuracy of multiple deep learning neural network architectures on sex classification with this dataset. Specifically, we evaluated methods representing three different 3D data modeling approaches: Resnet3D, PointNet++, and MeshNet. Despite the limited number of imaging samples, our testing results show that all three approaches achieve AUC scores above 0.9 after convergence. PointNet++ exhibits the highest accuracy, while MeshNet has the lowest. Our findings suggest that accuracy is not solely dependent on the sparsity of data representation but also on the architecture design, with MeshNet's lower accuracy likely due to the lack of a hierarchical structure for progressive data abstraction. Furthermore, we studied a problem related to sex determination, which is the analysis of the various morphological features that affect sex classification. We proposed and developed a new method based on morphological gradients to visualize features that influence model decision making. The method based on morphological gradients is an alternative to the standard saliency map, and the new method provides better visualization of feature importance. Our study is the first to develop and evaluate deep learning models for analyzing 3D facial skull images to identify imaging feature differences between individuals assigned male or female at birth. These findings may be useful for planning and evaluating craniofacial surgery, particularly gender-affirming procedures, such as facial feminization surgery.

Delayed, dramatic breast swelling in a transgender woman: a case report.

Background: As the number of gender-affirming procedures performed in the United States increases, physicians caring for gender-nonconforming patients, regardless of practice location and focus, will likely encounter transgender women with breast implants. Increasingly, transgender women are seeking breast feminization. However, this population is less consistently receiving surveillance and routine breast care than cisgender women. Aim: This report aims to add to the growing body of knowledge addressing breast augmentation complications in transgender women and to highlight disparities in healthcare. Methods: A case of breast implant-associated seroma at our institution was analyzed through chart review. A literature review was conducted using PubMed to gather all articles discussing breast implant-associated fluid collections in transgender patients. Prior to publication of this report, a Waiver of Consent was granted by the E.R.'s Institutional Review Board for the study under which this article was prepared. Results: Our patient was an African American transgender woman presenting initially at age 60 with significant asymmetry due to dramatic swelling of her left breast. The patient underwent bilateral breast augmentation outside of the United States 2 decades prior. The patient noted a gradual painless increase in her left breast size starting 3 years prior. She admitted that she was hesitant to seek a second opinion after being treated dismissively by another surgeon. Subsequent management included mammography and mirrored recommendations for late breast implant-associated seromas in cisgender patients: ultrasound, aspiration for cytology and culture, and removal of the implant and capsule. Outcomes: The fluid collection in our patient was determined to be a chronic hematoma and was managed surgically. Though this patient eventually achieved a good outcome, treatment was delayed due to barriers she faced as a transgender woman. Clinical Implications: Literature demonstrates that recommended management of late-onset breast-implant-associated seroma does not differ based on gender identity; however, transgender and GNC adults are more likely to receive less thorough care than cisgender women. Any patients undergoing breast augmentation with implants should be routinely evaluated for late complications, including seromas, which require prompt attention and methodical evaluation due to their potentially malignant nature. Strengths and Limitations: This article is limited in that it is a single report of breast seroma. It is strengthened by a PubMed review gathering all articles discussing breast-implant-associated fluid collections in transgender patients. Conclusion: We propose better education of physicians on how to care for transgender and gender-diverse patients should help mitigate the neglect and late presentation of such medical conditions in this vulnerable and marginalized population.

The Pediatric Neuroradiologist's Practical Guide to Capture and Evaluate Pre- and Postoperative Velopharyngeal Insufficiency.

Up to 30% of children with cleft palate will develop a severe speech disorder known as velopharyngeal insufficiency. Management of velopharyngeal insufficiency typically involves structural and functional assessment of the velum and pharynx by endoscopy and/or videofluoroscopy. These methods cannot provide direct evaluation of underlying velopharyngeal musculature. MR imaging offers an ideal imaging method, providing noninvasive, high-contrast, high-resolution imaging of soft-tissue anatomy. Furthermore, focused-speech MR imaging techniques can evaluate the function of the velum and pharynx during sustained speech production, providing critical physiologic information that supplements anatomic findings. The use of MR imaging for velopharyngeal evaluation is relatively novel, with limited literature describing its use in clinical radiology. Here we provide a practical approach to perform and interpret velopharyngeal MR imaging examinations. This article discusses the velopharyngeal MR imaging protocol, methods for interpreting velopharyngeal anatomy, and examples illustrating its clinical applications. This knowledge will provide radiologists with a new, noninvasive tool to offer to referring specialists.