Breast Asymmetry Research Articles

Diagnostic value of contrast-enhanced mammography in the characterization of breast asymmetry

BackgroundBreast asymmetry is a prevalent mammographic finding described in BI-RADS atlas as asymmetry, focal asymmetry, global asymmetry, and developing asymmetry. Mammography has a limited role in discrimination between benign and malignant asymmetry, and digital mammography can overlook up to 15–30% of breast tumors. The purpose of our study was to assess the role of contrast-enhanced mammography (CEM) in distinction between benign and malignant asymmetries.ResultsOut of the studied 540 indeterminate and suspicious asymmetries, and according to final histopathological results, 97/540 (17.9%) asymmetries were benign, 395/540(73%) asymmetries were malignant, 48/540 (8.9%) asymmetries were normal with no underlying pathology. After comparing results of sonomammography and CEM, CEM showed higher sensitivity (96.5% vs. 85.8), specificity (77.1% vs. 64.4%), NPV (88.8% vs. 62.7%), PPV (92.04% vs. 86.7%) and accuracy (91.3% vs. 80%).ConclusionsCEM has proven to be a valuable and beneficial imaging technicality for patients and radiologists, with breast cancer detection sensitivities superior to that of full-field digital mammography (FFDM) with ultrasonography (US).

Comparison of Outcome between Percutaneous Aspiration, Incision and Drainage In Case of Lactational and Non-Lactational Breast Abscess

A breast abscess is a localised collection of purulent material within the breast. Its first-line treatment was incision and drainage under general anaesthesia. But it prolonged the morbidity, whereas aspiration developed as a less invasive solution to the problem. Therefore, this study was conducted to compare the outcome of breast abscess management with both aspiration and incision and drainage techniques. It comprised 60 patients presented at LRH, Peshawar and LUMHS, Jamshoro, (July 2021 to December 2021). The mean age of the presented gyne patients was 34.78+10.55 years. Females with breast abscesses were allocated into two groups carrying 31 and 29 patients in lactational and non-lactational phases, respectively. Results revealed that post-surgical complications including scarring, breast asymmetry, mammary fistula and sepsis were significantly higher (p<0.05) in patients treated with incision and drainage as compared to the aspiration-managed women. Therefore, percutaneous aspiration was found more successful and effective than incision drainage. Keywords: Breast scarring; Mammary fistula; Pus drainage; Surgical complications.

Costal Cartilage Harvest Through a Small Incision in Asian Rhinoplasty After Breast Augmentation.

The costal cartilage is widely used in rhinoplasty. Although different surgical methods of costal cartilage harvest have been developed, few studies have reported the method of costal cartilage harvest for patients after breast augmentation. This study aims to provide our experience of costal cartilage harvest through a small incision approach. A retrospective review was performed for patients undergoing esthetic rhinoplasty with costal cartilage after breast augmentation between May 2019 and May 2021. Postoperative pain was evaluated with the Visual Analog Scale, and the scars at the donor site were assessed 1 year postoperatively with the Modified Vancouver Scar Scale. A total of 23 female patients were included. The average follow-up time was 21.4 months. No complications of massive bleeding, pleural injury, or breast implant injury during the surgery, wound dehiscence, or wound infection in the harvested site were observed. No patients complained of changes in breast morphology or breast asymmetry after costal cartilage harvest. Results of Visual Analog Scale for donor-site pain indicated pain in donor-site peaked at 12 hours after surgery and gradually decreased. All patients were satisfied with the scarring of the donor sites after surgery. The better scar performance, low complication rates, and high satisfaction among patients suggest that this is a safe technique to harvest costal cartilage with a small incision in rhinoplasty for patients after breast augmentation.

Supportive, Fitted, and Comfortable Bras for Individuals with Atypical Breast Shape/Size: Review of the Challenges and Proposed Roadmap

Individuals with atypical breast shape/size often find it quite challenging to obtain a comfortable, supportive, and fitted bra off-the-shelf. They include people with very large breasts, who have significant breast asymmetry, and/or have undergone mastectomy or mammoplasty. This paper provides insights in their challenges and attempts to fill the gap in terms of critical review of the current state of knowledge around the topic of bras. Poor and ill fitted bras are associated with breast, chest and shoulder pain, embarrassment, and an overall reduction in quality of life among others. Building upon the advantages and limitations of solutions to improve the fit, support and comfort of bras found in the literature, this paper proposes strategies to solve these challenges. As the problem is multidisciplinary, a human-centered interdisciplinary approach is key to ensure that all aspects are considered at all stages of the process. A modular design allows selecting the fabric characteristics based on the requirements of each bra part. In terms of materials, stretch woven fabrics offer a large potential in the production of bras to enhance the support provided by areas such as the under band and back panels. Bespoke manufacturing takes into account the specificities of each individual. The road map proposed here will contribute to enhance the quality of life of individuals with atypical breast shape/size.

Breast Asymmetry and Value of Contrast-Enhanced Spectral Mammography: Review Article

Breast Asymmetry and Value of Contrast-Enhanced Spectral Mammography: Review Article

Tuberous Breast, Deformities, and Asymmetries: A Retrospective Analysis Comparing Fat Grafting Versus Mastopexy and Breast Implants

BackgroundThe tuberous breast is considered a breast deformity characterized by varying degrees of herniation of the parenchyma, widened nipple-areolar complex (NAC), absence of the lower quadrants, and may involve several degrees of hypoplasia and asymmetry causing significant psychosocial distress.ObjectivesThe paper aimed to compare the results obtained in patients suffering tuberous breast treated with fat grafting (FG), with those of patients treated with a mastopexy and silicone implants (M-SI) also analyzing the influence of breast and chest deformities (degrees of hypoplasia and tuberous breast, volume and NAC asymmetry, pectus excavatum, and carinatum) in the reconstructive outcomes.MethodsA retrospective, case-control study was conducted. Thirty-five patients affected by tuberous breast with several degrees of hypoplasia and asymmetry were treated with FG, comparing results with those of 30 patients treated with M-SI. Postoperative follow-up took place at 1, 3, 7, 12, 24, 48, weeks, and then annually for 2 years.Results 77% (n = 27) of patients treated with two FG procedures showed excellent results after 1 year compared with the patients treated with only one M-SI procedure, who showed the same results in 73% (n = 22) of cases, but the naturalness and the satisfaction degree in the FG group were higher than that in the M-SI group (p < .0001 vs. M-SI group).ConclusionsPatients treated with FG showed natural breasts without scars and excellent cosmetic results after two procedures. Patients treated with M-SI showed more evident and lasting results after only one procedure, presenting though scars and less natural results.Level of Evidence IVThis 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

Inferior Pedicle Reduction Mammoplasty as Corrective Surgery after Breast Conserving Surgery and Radiation Therapy.

Background/Aim—Twenty patients had corrective reconstruction surgery by means of a reduction mammaplasty or mastopexy after a previous BCS (Breast Conserving Surgery) and RT (Radiation Therapy); the risk factors and post-operative complications were reported in order to define a safe and effective technique for reduction mammaplasty in previously irradiated breast cancer patients. Materials and Methods—From June 2011 to December 2019, 20 pts. were operated on at the Breast Surgery Clinic of San Martino Policlinic Hospital, Genoa, Italy. Pre- and post-operative parameters included clinic-pathological features of the primary tumor; a lapse of time from primary radio-surgery; the extent of follow-up; the rate of post-operative wound infections; the persistence of breast asymmetry, and a post-operative patient satisfaction index by means of a BREAST-Q questionnaire. Results—Three patients (15%) developed minor complications in the irradiated breast, but no complication was observed into the non-irradiated breast. No statistically significant correlation was found between the post-operative complications and the risk factors. The statistical analysis of BREAST-Q questionnaire responses gave an average patient’s satisfaction index that was equal to 90.8/100 (range: 44 to 100). Conclusions—Inferior pedicle reduction mammoplasty is an effective reduction mammoplasty technique in regard to the extent of breast tissues that are to be removed both in irradiated and contralateral breast; moreover, the incidence of post-operative complications is clearly limited when a careful technique is adopted, and it can be reasonably applied also in patients with co-morbidity factors.

Immediate prosthetic breast reconstruction after removal of the polyacrylamide hydrogel (PAAG) through a small areolar incision assisted with an endoscope

BackgroundTo identify the feasibility, safety, cosmetic outcomes and patient satisfaction of immediate prosthetic breast reconstruction after removal of Polyacrylamide Hydrogel (PAAG) through a small areolar incision assisted with an endoscope.MethodsThis was a retrospective study. Medical records of 87 patients who underwent PAAG removal were reviewed retrospectively from February 2010 to December 2019. These patients were dichotomized based on whether they accepted immediate prosthetic breast reconstruction after PAAG removal or not. A comprehensive analysis on the data was conducted to observe the surgical results, cosmetic outcomes, health-related quality of life (HRQOL) and patient satisfaction.ResultsSixty-two patients underwent PAAG removal through a small areolar incision assisted with an endoscope, while another 25 patients underwent further immediate prosthetic breast reconstruction after PAAG removal. All the patients recovered smoothly after operation. In the immediate breast reconstructed group, most of the breasts were natural in appearance, but one patient had mild nipple and breast asymmetry, and another had mild breast asymmetry. Three patients had PAAG residual, and one of them accepted fine needle aspiration. The cosmetic satisfaction rate was 88% and 92% by surgeons and patients, respectively. In the other group, seven patients suffered from PAAG residual, one patient suffered from postoperative bleeding, and five patients suffered from skin laxity. The BREAST-Q scores revealed that patients who accepted immediate breast reconstruction had significant better outcomes in psychosocial well-being (p = 0.030), satisfaction with breasts (p = 0.021), when compared to patients who only accepted PAAG removal, while similar in sexual well-being (p = 0.081), physical well-being chest (p = 0.124), and satisfaction with outcomes (p = 0.068), and satisfaction with care (p = 0.077).ConclusionImmediate prosthetic breast reconstruction after PAAG removal through a small areolar incision aided with an endoscope might be a viable and safe technique, with better psychosocial well-being and satisfaction with breasts.

Classifications des asymétries mammaires et indications chirurgicales

Constitutional breast asymmetries are responsible not only for esthetic unsightliness, but also, at times, for psychological disorders, and medical management is necessitated. While surgical treatment is the only viable therapeutic option, given the wide variety of morphological presentations of mammary asymmetries, the surgeon is called upon to be well versed in breast surgery techniques. The authors have put forward a classification of mammary asymmetries and principles of treatment.

Pediatric endoscopic subcutaneous mastectomy (pesma) with liposuction in adolescents with gynecomastia

BackgroundSurgical techniques for treatment of gynecomastia are increasingly less invasive. We described technical standardization of pediatric endoscopic subcutaneous mastectomy (PESMA) with liposuction.MethodsAll adolescents with primary gynecomastia, operated using PESMA with liposuction over the period June 2014–July 2021, were included. The video recording of procedures was analyzed to standardize the operative technique. After patient installation, 3 trocars were placed on the mid-axillary line. The technique included 5 steps: (1) subcutaneous injection of lipolysis solution and liposuction; (2) creation of working space using an inflated balloon; (3) gland dissection using 5-mm sealing device; (4) specimen extraction through the largest trocar orifice; and (5) placement of suction drainage tube.ResultsTwenty-four male adolescents, operated for Simon’s grade 2B and 3 gynecomastia using PESMA with liposuction over the study period, were included. Mean patient age was 16 years (range 15–18). Gynecomastia was bilateral in 19/24 (79.2%) and unilateral in 5/24 (20.8%). One (4.1%) conversion to open was reported. The mean operative time was 87 min (range 98–160) for unilateral and 160 min (range 140–250) for bilateral procedure. The mean length of stay was 2.2 days (range 1–4). Patients wore a thoracic belt for 15 up to 30 days postoperatively. Post-operative complications occurred in 5/24 (20.8%): 2- or 3 mm second-degree burns in 4 (16.7%) and subcutaneous seroma in 1 (4.1%). All complications were Clavien 2 grade and did not require further treatment. Aesthetic outcomes were very good in 21/24 (87.5%). Three (12.5%) boys had persistent minimal breast asymmetry but did never perceive it negatively.ConclusionPESMA combined with liposuction was feasible and safe for surgical treatment of gynecomastia in this selected cohort of patients. Although challenging, this procedure provided good aesthetic results, with no scars on the anterior thoracic wall. Standardization of the operative technique was a key point for successful outcome.

287 Retrospective Review of a Single Surgeon 5-Year Experience of Paediatric Breast Reconstruction - Challenges, Experience, and the Increasing Role of Lipofilling

Abstract Aim This case series reviews the presentation, clinical and surgical management of paediatric breast cases undertaken by a single surgeon. The series demonstrates the powerful role of lipomodelling when used with breast reshaping techniques to achieve good outcomes and avoid the need to commit young patients to breast implants. Method Retrospective analysis of paediatric breast referrals to a single surgeon at a regional plastic surgery breast reconstruction unit over a 5-year period. Results In a 5-year period, 15 cases which presented in childhood to a tertiary paediatric centre were referred on to our regional plastic surgery breast reconstruction unit. Two patients underwent correction of breast hypoplasia secondary to Poland's syndrome. Nine patients presented for breast asymmetry with associated tuberous deformity. One patient had maldevelopment of a breast secondary to a burn's contracture. Two patients presented with gigantomastia and one patient with juvenile fibroadenomas. Conclusions Paediatric breast abnormalities represent a small but important caseload for a breast reconstructive surgeon. This case series demonstrates the need for careful assessment and an individualised surgical plan for each patient. The surgical plan must achieve a satisfactory outcome whilst minimising the need for further procedures as the patient grows. It is the senior surgeon's preference to avoid breast implant-based reconstruction where possible. In all but one case lipomodelling combined with reshaping of the native tissue was used to good effect.

Unilateral immediate deep inferior epigastric artery perforator flap breast reconstruction following skin sparing mastectomy: A comparative study on revision surgeries to improve breast symmetry.

The number of revision surgeries to improve breast asymmetry after deep inferior epigastric perforator (DIEP) flap breast reconstruction is still high worldwide with impact on both patients and healthcare systems. These procedures include fat grafting, contralateral breast symmetrization, scar revision, flap repositioning and remodeling. A previously published DIEP flap insetting algorithm has proven to be effective in selecting patient-tailored strategies to achieve excellent aesthetic outcomes. This study investigated whether this insetting algorithm was effective in reducing revision surgeries in patients undergoing SSM and immediate DIEP flap breast reconstruction to achieve the goal of a one-stage reconstruction. This retrospective case-control study included 60 patients (group A) treated without the DIEP flap standardized insetting algorithm and 60 patients (group B) treated with the standardized insetting algorithm, which considers among its variables the type of breast to be reconstructed, abdominal tissue thickness, rotation due to harvesting side. Demographic data, operative data, complications and number of revision surgeries were recorded. One hundred and twenty primary and 106 revision surgeries were performed. Groups were homogenous for age (p=.32), body mass index (p=.77), flap weight (p=.7), operative time (p=.87) and early complications (p=.78). When excluding isolated nipple reconstruction from the revision surgeries, one-stage reconstruction was successfully performed in 26 patients in group A (43.3%) and 39 patients (65.0%) in group B, with a statistically significant difference between the groups (p=.003). The introduction of a standardized insetting algorithm for immediate unilateral DIEP flap breast reconstruction can be effective in reducing the number of revision surgeries for breast asymmetry, making a one-stage reconstruction an achievable and reliable target.

Unilateral autoinflation of a saline-filled breast implant initially diagnosed as capsular contracture: a case report and review of the literature

Spontaneous inflation of saline breast implants is a rare phenomenon. In this case report, we share our experience treating a patient who complained of asymmetric breasts from what appeared to be a straightforward case of capsular contracture. Spontaneous autoinflation of the right breast implant was subsequently found to be the cause of breast asymmetry and hardness. The presentation, diagnostic challenge, management, and mechanism of this rare phenomenon are presented here.

Nonsubjective Assessment of Shape, Volume and Symmetry during Breast Augmentation with Handheld 3D Device.

Three-dimensional Surface Imaging (3DSI) has become a valuable tool for planning and documenting surgical procedures. Although surface scanners have allowed for a better understanding of breast shape, size, and asymmetry during patient consultation, its use has not been included in intraoperative assessment so far. Validation of the reliability of the intraoperative use of a portable handheld 3DSI equipment as a tool to evaluate morphological changes during breast augmentation surgery. The patients who underwent bilateral subpectoral breast augmentation through an inframammary incision were included in this study. Intraoperative 3DSI was performed with the Artec Eva device, allowing for visualization of the surgical area before incision, after use of breast sizers and implant, and after wound closure. Intraoperatively manual measurements of breast distances and volume changes due to known sizer and implant volumes were in comparison with digital measurements calculated from 3DSI of the surgical area. Bilateral breasts of 40 patients were 3D photographed before incision and after suture successfully. A further 108 implant sizer uses were digitally documented. There was no significant difference between manual tape measurement and digital breast distance measurement. Pre- to postoperative 3D volume change showed no significant difference to the known sizer and implant volume.

Correction of breast asymmetry by autologous fat grafting with the aid of 3D laser-scanning technology

BackgroundCurrently, the lack of clinically accurate measurement and evaluation methods for breast asymmetry has considerably limited the use of autologous fat grafting in the correction of breast asymmetry. ObjectiveThis study calculated the volume difference in the bilateral breasts by three-dimensional (3D) laser scanning technology, established a bridge between digitalization and surgery to guide the correction of breast asymmetry by autologous fat grafting, and evaluated the surgical effect. MethodsIn the experimental group (3D group), the measurement range was defined by standardized methods, the algorithm to calculate the volume difference in the bilateral breasts was determined by the established software instructions, and the volume of intraoperative autologous fat grafting was guided by personalized data. In the control group, the volume of intraoperative autologous fat grafting was determined based on the surgeon's visual assessment and surgical experience. ResultsThe volume difference in the bilateral breasts was less at 12 months after surgery (P < 0.05), the satisfaction of patients was higher (P < 0.05), and the reoperation rate was lower (P < 0.05). The incidence of postoperative complications was low in both groups (P > 0.05). Conclusions3D laser scanning technology can be used as a bridge between digitalization and surgery to significantly improve the surgical effect of autologous fat grafting in the correction of breast asymmetry, with high patient satisfaction and high clinical application value.

Methods of Esthetic Assessment after Adjuvant Whole-Breast Radiotherapy in Breast Cancer Patients: Evaluation of the BCCT.core Software and Patients' and Physicians' Assessment from the Randomized IMRT-MC2 Trial.

Simple SummaryTo validate the BCCT.core software, the present analysis compares the esthetics assessment by the software in relation to patients’ and physicians’ rating in breast cancer patients after surgery and adjuvant radiotherapy. Agreement rates of the different assessments and their correlation with breast asymmetry indices were evaluated. The assessments of the software and the physicians were significantly correlated with all asymmetry indices, while for patients’ self-assessment, this general correlation was first seen after 2 years. Only a slight agreement between the BCCT.core software and the physicians’ or patients’ assessment was seen, while a moderate and substantial agreement was detected between the physicians’ and the patients’ assessments. The BCCT.core software is a reliable tool to measure asymmetries, but may not sufficiently evaluate the esthetic outcome as perceived by patients. It may be more appropriate for a long-term follow-up, when symmetry seems to increase in importance.The present analysis compares the esthetics assessment by the BCCT.core software in relation to patients’ and physicians’ ratings, based on the IMRT-MC2 trial. Within this trial, breast cancer patients received breast-conserving surgery (BCS) and adjuvant radiotherapy. At the baseline, 6 weeks, and 2 years after radiotherapy, photos of the breasts were assessed by the software and patients’ and physicians’ assessments were performed. Agreement rates of the assessments and their correlation with breast asymmetry indices were evaluated. The assessments of the software and the physicians were significantly correlated with asymmetry indices. Before and 6 weeks after radiotherapy, the patients’ self-assessment was only correlated with the lower breast contour (LBC) and upward nipple retraction (UNR), while after 2 years, there was also a correlation with other indices. Only a slight agreement between the BCCT.core software and the physicians’ or patients’ assessment was seen, while a moderate and substantial agreement was detected between the physicians’ and the patients’ assessment after 6 weeks and 2 years, respectively. The BCCT.core software is a reliable tool to measure asymmetries, but may not sufficiently evaluate the esthetic outcome as perceived by patients. It may be more appropriate for a long-term follow-up, when symmetry appears to increase in importance.

Objective evaluation of volumetric changes during breast augmentation using intraoperative three-dimensional surface imaging

Breast volume estimation and implant size are crucial factors to achieve a symmetrical result in esthetic and reconstructive breast surgery. Although three-dimensional surface imaging (3DSI) has allowed for a better understanding of breast shape, size, and asymmetry during patient consultation, its use has been limited regarding intraoperative decision-making. To validate the intraoperative use of a portable hand-held 3D surface imaging device as an objective tool to assess volumetric changes during breast augmentation surgery. Patients receiving bilateral, submuscular breast augmentation were enrolled for this study. Intraoperative 3DSI was conducted using the Sense 3D scanner, allowing for digitalization of the operating field. Intraoperatively gauged volume changes caused by known implant volumes were compared with digital measurements calculated from 3D surface images of the operating field. Digital intraoperative breast volumes were compared to the pre- and postoperative Vectra XT reference system. Eighty individual breasts of 40 patients were successfully 3D imaged before incision and after wound closure. There was no significant difference between digital breast volumes by intraoperative and outpatient 3DSI. Intraoperative pre- to postoperative 3D breast volume change showed no significant difference to the known implant volume (p=0.124, mean deviation of 5.8±24.3mL and 2.0±9.0%). Our findings showed a high correlation regarding intraoperative digital breast volumetric changes. Intraoperative use of 3DSI yielded objective data during breast augmentation. This novel technique could beneficially impact future breast implant selection, especially in cases with breast asymmetry and the need for differently sized implants.

Poland syndrome

Poland syndrome is a congenital anomaly with unilateral agenesis or hypoplasia of the pectoral muscles, deformity of the anterior chest wall and upper extremity anomalies. In patients with Poland syndrome, varying rates of breast asymmetry, from hypomastia to amastia, accompany. It is observed that the incidence of dextrocardia is increased in patients with left-sided Poland syndrome. Vital lung capacity may be reduced due to anterior chest wall deformity. This syndrome is thought to be due to a temporary impairment of circulation in the arteria subclavia or any of its branches or hypoplasia of these vessels during the development of the upper extremities in the intrauterine period. We aimed to emphasize the characteristics of Poland syndrome in a 26-yearold female case. On physical examination, pectus excavatum deformity was observed besides the absence of left pectoralis major and minor muscles with plica axillaris anterior. In terms of congenital or acquired pathologies that m ay accompany, the cases should be evaluated clinically in detail and followed up.

Clinical application of expanded internal mammary artery perforator flap combined with vascular supercharge in reconstruction of faciocervical scar

Objective: To summarize the clinical experience of expanded internal mammary artery perforator (IMAP) flap combined with vascular supercharge in reconstruction of faciocervical scar. Methods: The retrospective observational study was conducted. From September 2012 to May 2021, 23 patients with postburn or posttraumatic faciocervical scars who met the inclusion criteria were admitted to Shanghai Ninth People's Hospital of Shanghai Jiao Tong University School of Medicine, including 18 males and 5 females, aged from 11 to 58 years, all of whom were reconstructed with expanded IMAP flaps. At the first stage, one or two skin and soft tissue expander (s) with appropriate rated capacity were implanted in the anterior chest area according to the location and size of the scars. The IMAP, thoracic branch of supraclavicular artery, and lateral thoracic artery were preserved during the operation. The skin and soft tissue expanders were inflated with normal saline after the operation. The flaps were transferred during the second stage. The dominant IMAP was determined preoperatively using color Doppler ultrasound (CDU) blood flow detector. The faciocervical scars were removed, forming wounds with areas of 9 cm×7 cm-28 cm×12 cm, and the perforators of superficial temporal artery and vein or facial artery and vein were preserved during the operation. The flaps were designed according to the area and size of the wounds after scar resection with the dominant IMAP as the pedicle. Single-pedicle IMAP flaps were used to repair small and medium-sized wounds. For larger defects, the blood perfusion areas of vessels in the anterior chest were evaluated by indocyanine green angiography (ICGA). In situations where the IMAP was insufficient to nourish the entire flap, double-pedicle flaps were designed by using the thoracic branch of supraclavicular artery or lateral thoracic artery for supercharging. Pedicled or free flap transfer was selected according to the distance between the donor areas and recipient areas. After transplantation of flaps, ICGA was conducted again to evaluate blood perfusion of the flaps. The donor sites of flaps were all closed by suturing directly. Statistics were recorded, including the number, rated capacity, normal saline injection volume, and expansion period of skin and soft tissue expanders, the location of the dominant IMAP, the total number of the flaps used, the number of flaps with different types of vascular pedicles, the flap area, the flap survival after the second stage surgery, the occurrence of common complications in the donor and recipient areas, and the condition of follow-up. Results: Totally 25 skin and soft tissue expanders were used in this group of patients, with rated capacity of 200-500 mL, normal saline injection volume of 855-2 055 mL, and expansion period of 4-16 months. The dominant IMAP was detected in the second intercostal space (20 sides) or the third intercostal space (5 sides) before surgery. A total of 25 expanded flaps were excised, including 2 pedicled IMAP flaps, 11 free IMAP flaps, 4 pedicled thoracic branch of supraclavicular artery+free IMAP flaps, and 8 free IMAP+lateral thoracic artery flaps, with flap areas of 10 cm×8 cm-30 cm×14 cm. After the second stage surgery, tip necrosis of flaps in three patients occurred, which healed after routine dressing changes; one patient developed arterial embolism and local torsion on the vascular pedicle at the anastomosis of IMAP and facial artery, and the blood supply recovered after thrombectomy and vascular re-anastomosis. Fourteen patients underwent flap thinning surgery in 1 month to 6 months after the second stage surgery. The follow-up for 4 months to 9 years showed that all patients had improved appearances of flaps and functions of face and neck and linear scar in the donor sites of flaps, and one female patient had obvious nipple displacement and bilateral breast asymmetry. Conclusions: The expanded IMAP flap is matched in color and texture with that of the face and neck, and its incision causes little damage to the chest donor sites. When combined with vascular supercharge, a double-pedicle flap can be designed flexibly to further enhance the blood supply and expand the flap incision area, which is a good choice for reconstruction of large faciocervical scar.

A generative adversarial network for synthetization of regions of interest based on digital mammograms

Deep learning (DL) models are becoming pervasive and applicable to computer vision, image processing, and synthesis problems. The performance of these models is often improved through architectural configuration, tweaks, the use of enormous training data, and skillful selection of hyperparameters. The application of deep learning models to medical image processing has yielded interesting performance, capable of correctly detecting abnormalities in medical digital images, making them surpass human physicians. However, advancing research in this domain largely relies on the availability of training datasets. These datasets are sometimes not publicly accessible, insufficient for training, and may also be characterized by a class imbalance among samples. As a result, inadequate training samples and difficulty in accessing new datasets for training deep learning models limit performance and research into new domains. Hence, generative adversarial networks (GANs) have been proposed to mediate this gap by synthesizing data similar to real sample images. However, we observed that benchmark datasets with regions of interest (ROIs) for characterizing abnormalities in breast cancer using digital mammography do not contain sufficient data with a fair distribution of all cases of abnormalities. For instance, the architectural distortion and breast asymmetry in digital mammograms are sparsely distributed across most publicly available datasets. This paper proposes a GAN model, named ROImammoGAN, which synthesizes ROI-based digital mammograms. Our approach involves the design of a GAN model consisting of both a generator and a discriminator to learn a hierarchy of representations for abnormalities in digital mammograms. Attention is given to architectural distortion, asymmetry, mass, and microcalcification abnormalities so that training distinctively learns the features of each abnormality and generates sufficient images for each category. The proposed GAN model was applied to MIAS datasets, and the performance evaluation yielded a competitive accuracy for the synthesized samples. In addition, the quality of the images generated was also evaluated using PSNR, SSIM, FSIM, BRISQUE, PQUE, NIQUE, FID, and geometry scores. The results showed that ROImammoGAN performed competitively with state-of-the-art GANs. The outcome of this study is a model for augmenting CNN models with ROI-centric image samples for the characterization of abnormalities in breast images.