Current surgical techniques for nipple reduction: A literature review.

BACKGROUND: Macrothelia, enlarged nipples, is a relatively uncommon condition causing psychological distress in both sexes. However, to date, there is no comprehensive comparison of the spectrum of surgical techniques for nipple reduction. This review summarises the current practices to guide surgical approach to macrothelia. METHODS: A literature review was performed using the PubMed database by searching for the following words: nipple areola plasty OR nipple areola complex plasty OR nipple areola reduction OR nipple areola complex reduction OR nipple areola hypertrophy OR nipple areola complex hypertrophy OR nipple-areola complex hypertrophy OR macrothelia AND techniques OR classification OR indications OR treatment OR reduction. Additional articles were selected after reviewing references of identified articles. RESULTS: Thirty articles were selected after applying inclusion criteria to identify prospective and retrospective studies evaluating and/or describing different techniques, outcomes, complications and patient satisfaction. Reduction of the nipple was described in 639 patients, 582 females and 57 males. The thirty articles selected were case reports and clinical observations. No systematic or unsystematic reviews were found. Five different techniques were described, namely, circumcision, amputation, wedge resection, simple grafting and flaps. Patient satisfaction rates were high. Only a few cases documented sustained ability to breastfeed after the procedure. Complication rates were low and mentioned in only few studies. CONCLUSION: All techniques resulted in high patient satisfaction and low complication rates. However, current practices are exceedingly diverse, and there is currently no common classification system, which makes comparison between surgical techniques for nipple reduction challenging. The choice of surgical technique must be based on individual assessment. Clinical guidelines are challenging owing to the heterogeneity of the studies reviewed.

Malignant transformation of a non-healing traumatic wound on the lower extremity: A case report.

OBJECTIVE: Malignant transformation of chronic non-healing wounds is often overlooked. If a chronic wound fails to heal, or if there are changes in the characteristics of a wound, a biopsy should be performed. METHODS: This case is presented in line with SCARE guidelines. PRESENTATION OF CASE: We present a case of a man with a non-healing traumatic wound over two years in which a basal cell carcinoma was diagnosed by biopsy. The basal cell carcinoma was radically excised and the defect was closed using a split thickness skin transplant. DISCUSSION: The term Marjolin's ulcer, pathophysiology and recommended treatment. CONCLUSION: Delayed diagnosis of malignancy in chronic wounds can lead to a worsened prognosis and therefore it is important to exclude a malignant aetiology. Malignant transformation of chronic wounds is not common but Marjolin's ulcer should be considered.

[Diagnostics, treatment and prognosis in breast cancer during pregnancy].

Breast cancer is the second most common form of cancer diagnosed during pregnancy. The diagnosis and treatment of breast cancer during pregnancy requires multidisciplinary efforts to treat the cancer while protecting the foetus. Pregnancy-related changes in the breast make the diagnosis particularly challenging. Surgery is possible during all three trimesters. Chemotherapy can be administered in the second and third trimesters without increased risk of foetal malformations. Radiation, endocrine and biological therapies however, must be postponed until after delivery.

[Evaluation and treatment of nipple secretion].

Nipple secretion is a common condition; it can occur in men and women, and be uni- or bilateral. It is related to hormonal changes, physical stimulation, intracerebral processes and certain drugs, and it is divided into three types: galactorrhoea, clear/bloody or viscous. Only the clear/bloody type is an indication of breast malignancy. Malignancy should always be ruled out in the presence of breast tumours. Treatment is determined by aetiology, and can vary from patient education, medications to surgery.

Incidental Treatment of a Subclinical Chronic Tension-Type Headache by Cosmetic Use of Botulinum Toxin A: A Case Report.

BACKGROUND: Headache is a common disorder of the nervous system; chronic headache in particular may affect quality of life negatively. The pathophysiology is multifactorial and not completely elucidated. Studies have demonstrated the beneficial effects of botulinum toxin A on chronic migraine headaches, but failed to show the same effect on chronic tension-type headaches. METHODS: We present the case of a 32-year-old woman who after receiving cosmetic injections with botulinum toxin A for fine lines of the forehead experienced relief of subclinical tension-type headaches. CONCLUSIONS: Although the effect of botulinum toxin A on chronic tension-type headaches is limited, several studies demonstrate its pain-modulating effects, and as such it is worth paying attention to this potential beneficial effect when performing cosmetic injections with botulinum toxin A.

[Lipoatrophy after insulin injections can be treated with lipofilling].

Lipoatrophy is a known, albeit rare, side effect of insulin injections. We describe a case concerning a 17-year-old woman with insulin-dependent diabetes, who was treated with an insulin pump. In the areas surrounding the injection point subcutaneous lipoatrophy occurred. Such lipoatrophy is of cosmetic importance, and it may incur glycaemic imbalance due to altered and unpredictable absorption of insulin in the atrophied areas. With no spontaneous regeneration of the atrophied areas observed the patient was successfully treated with lipofilling in the atrophied areas.

Deep venous thrombosis as the single sign of unexpected metastatic urinary tract cancer in a patient with a history of cutaneous melanoma: A case report.

INTRODUCTION: Cancer is a recognized risk factor of venous thromboembolism (VTE) as it induces a prothrombotic state through various mechanisms of activation of coagulation. Recognizing occult cancer as a risk factor is equally important. In patients with no known thromboembolic risk factors, utilizing PET/CT as a screening tool may be considered in order to reveal occult malignancy associated with otherwise unexplainable VTE. METHODS: This case report has been reported in line with the SCARE criteria. PRESENTATION OF CASE: We describe a case of deep venous thrombosis of the lower leg as the single sign of metastatic urinary tract cancer. The patient had a history of cutaneous melanoma but no thromboembolic risk factors. Following treatment for deep venous thrombosis, the patient was referred directly to the plastic surgery department for further examination including PET/CT due to suspicion of metastatic melanoma. DISCUSSION: Screening for occult cancer in patients with unprovoked VTE has so far not been shown to benefit survival. As new treatments emerge, significant improvement in prognosis might be expected with early diagnosis of occult cancer and initiation of treatment. Thus an open mind should be kept towards utilizing advanced diagnostic tools such as PET/CT to screen for occult cancer in patients presenting with unprovoked VTE. CONCLUSION: This case highlights the importance of considering all possible causes and utilizing targeted diagnostic tools when assessing a patient with seemingly unprovoked deep venous thrombosis. A whole-body PET/CT scan ultimately proved significant in revealing occult metastatic cancer of a completely different origin than expected.

[Inverted nipples].

Inverted nipples is an anatomical variation which can be uni- or bilateral, congenital or acquired. The degree of inversion can vary from slight to severe. Treatment can be surgical or non-surgical and should depend on the degree of functional problems. Non-surgical treatment can be beneficial, does not risk affecting sensibility, spares the lactiferous ducts, and therefore does not risk any interference with breast-feeding. Surgical options should only be considered when non-surgical treatment is insufficient.

A Fast-Track Referral System for Skin Lesions Suspicious of Melanoma: Population-Based Cross-Sectional Study from a Plastic Surgery Center.

Introduction. To minimize delay between presentation, diagnosis, and treatment of cutaneous melanoma (CM), a national fast-track referral system (FTRS) was implemented in Denmark. The aim of this study was to analyze the referral patterns to our department of skin lesions suspicious of melanoma in the FTRS. Methods. Patients referred to the Department of Plastic Surgery and Breast Surgery in Zealand University Hospital were registered prospectively over a 1-year period in 2014. A cross-sectional study was performed analyzing referral patterns, including patient and tumor characteristics. Results. A total of 556 patients were registered as referred to the center in the FTRS for skin lesions suspicious of melanoma. Among these, a total of 312 patients (56.1%) were diagnosed with CM. Additionally, 41 (7.4%) of the referred patients were diagnosed with in situ melanoma. Conclusion. In total, 353 (63.5%) patients had a malignant or premalignant melanocytic skin lesion. When only considering patients who where referred without a biopsy, the diagnostic accuracy for GPs and dermatologists was 29% and 45%, respectively. We suggest that efforts of adequate training for the referring physicians in diagnosing melanocytic skin lesions will increase diagnostic accuracy, leading to larger capacity in secondary care for the required treatment of malignant skin lesions.

Release and Reconstruction of a Postburn Deformed Breast in a Young Woman.

Burn injuries to the anterior chest wall in the young woman may cause disfiguration or lack of development of the breasts during puberty. Often the patients are referred after puberty with an apparent lack of breast development due to firm postburn scar tissue constricting the anterior chest wall. We report a case where a young female with a postburn disfiguration and apparent diminished breast development was reconstructed successfully with incision only through the restricting burn scar, a periareolar skin excision and split-thickness skin grafting of the subsequent outburst of constricted breast tissue.

[Breast implant-associated anaplastic large-cell lymphoma]. / Anaplastisk storcellet lymfomassocieret til brystimplantater.

Breast implant-associated anaplastic large-cell lymphoma (BIA-ALCL) is a rare entity. Due to the lack of awareness of BIA-ALCL, patients with prior history of breast implants who present with non-specific implant-related complications might experience a delay in diagnosis and appropriate treatment of this distinct condition. There are still no evidence-based guidelines on how this condition should be diagnosed, treated or followed because of the rarity of available data. We review current literature in order to raise awareness and discuss management options of this unique clinical entity.

[Merkel cell carcinoma is a rare, aggressive neuroendocrine skin cancer]. / Merkelcellekarcinom er en aggressivneuroendokrin hudtumor.

Merkel cell carcinoma (MCC) is a rare, aggressive skin cancer with a poor survival rate. The low incidence and lack of characteristic manifestation of MCC often cause an incorrect diagnosis. A 92-year-old male presented with an asymptomatic, smooth lesion on the right cheek, which was initially diagnosed as a basal cell carcinoma. After histological diagnosis of MCC the patient underwent radical surgery, but developed metastases later. Attention to the diagnosis of this condition, patient history and initial presentation can provide clues in order to offer the right treatment with minimal delay.

Rectus abdominis diastasis.

Because of the lack of agreement on when rectus diastasis (RD) is pathologic, the aim was to investigate indications for surgical repair. This study presents classifications of RD, current knowledge on the relation to pregnancy, and conservative and surgical management. A systematic search in Pubmed, Embase, Cochrane, and Cinahl revealed 437 studies. Inclusion criteria were applied according to the above mentioned subjects of interest. In total 28 studies were included, representing 3725 patients, 11 of these by assessing reference lists of included studies. Only one RCT was found; most studies were case-series lacking statistical analysis. RD was common in post-partum women. Antepartum activity level may have a protective effect on RD and exercise may improve post-partum symptoms of RD. Repair was done during abdominoplasty or laparoscopically. The patient-satisfaction was high and long-term recurrence was reported by one study, while five reported no recurrence. Overall major complications were few, while minor complications were primarily seroma and wound complications. RD is by itself not a true hernia and, therefore, not associated with the risk of strangulation. Repair is mostly done due to cosmetic reasons. The condition does not necessarily require repair, and conservative management may be an alternative. If done, the protrusion of the abdomen, rather than the diastasis itself should influence the decision of repair. It is recommended that future studies use the established classifications (e.g. Beer, Rath, or Nahas) when reporting RD and long-term outcome of treatment. Comparison of surgical techniques and studies that address and compare conservative management with surgery are needed.

[Limited evidence for negative pressure wound treatment of skin transplants and closed surgical wounds]. / Begrænset evidens for undertryksbehandling af hudtransplantater og lukkede kirurgiske sår--en gennemgang af et Cochranereview.

The indications for negative pressure wound treatment (NPWT) are increasing, e.g. for fixation of skin transplant and primary closed surgical wounds. The evidence for indications and positive effects are limited. NPWT should exclusively be used for fixation of split thickness skin transplants when immobilisation is otherwise difficult and for primary closed surgical wounds in selected patients at risk. Future high-quality investigations are necessary to pinpoint indications for topical negative pressure therapy, the effect of the different NPWT-modalities, and the overall economy compared to conventional bandages.

Increased morbidity in patients undergoing abdominoplasty after laparoscopic gastric bypass.

INTRODUCTION: 30-40% of the adult population in Denmark are overweight and 10-13% are obese. The number of bariatric operations reached 3,000 in 2009, and it is expected that a third or more of the patients need corrective plastic surgery. MATERIAL AND METHODS: Medical charts of all patients who had abdominoplasty performed during a 2.5-year period. We included 72 patients of whom 21 had lost weight after bariatric surgery and 51 patients had lost weight through diet and exercise or had not been overweight. RESULTS: The overall complication rate was 21% (43% of the post-bariatric patients and 12% of the non-post-bariatric patients, p < 0.01). When adjusted for the maximum body mass index (BMI) and BMI at the time of abdominoplasty, post-bariatric patients still had a higher complication rate than non post-bariatric patients (OR = 4.8; 95% CI: 0.92-25.04). Post-bariatric patients had a significantly higher maximum weight, weight at the time of abdominoplasty and had lost more BMI units. CONCLUSION: Our data show that post-bariatric patients who have an abdominoplasty performed suffer a high complication rate which appears to be higher than that of patients who do not have bariatric surgery. We have also shown a tendency towards increased costs of abdominoplasty in post-bariatric patients due to a slightly longer operating time and more postoperative office visits.

[Paraffin oil injection in bodybuilders calls for preventive action]. / Paraffininjektioner hos bodybuildere skal forebygges.

Injection of paraffin oil to change physical configuration is an obsolete procedure from 1899, revived by bodybuilders as an alternative to intramuscular injections of steroids. Paraffin oil has destructive consequences: skin inflammation, hard oedema, sterile abscesses, diffuse lymphangitis and paraffinomas. We report a case of a 24-year-old male bodybuilder who self-injected one litre of paraffin oil in each arm. Hazard notice and advice to bodybuilders with potential risk attitude or "reverse anorexia" are warranted.