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IMAGES injection to correct defects in the upper and inner portion of both breasts using fat obtained through liposuction, 40 days before presentation at our hospital. Her initial surgery was performed in an aesthetic plastic surgery clinic, and the amount of fat extracted and transplanted was not precisely known. Ten days before presentation at our hospital, the patient visited the clinic with a slight fever accompanied by edema, pain, and calor in the left breast. She received antibiotic treatment with ceftriaxone (CJ CheilJedang Corp., Icheon, Korea) and metronidazole (Kunhwa Corp., Gongju, Korea), but did not improve. At presentation, the swelling and calor in her left breast had worsened and both breasts had severe edema (Fig. 1). Blood tests showed an elevated C-reactive protein (CRP) level of 8.43 mg/dL, erythrocyte sedimenta- tion rate (ESR) at 120 mm/hr, and white blood cell (WBC) count at 18,800 cells/µL. Emergency surgery was per- formed using a periareolar incision, and the abscess was drained. As the incisions were made, necrotic and melted fat that was seen as a clear, greasy, liquid discharge, which was followed by a yellowish discharge and finally a sticky, foamy discharge emerged. All were drained and removed together along with the necrotic tissue. The abscess in the left breast was drained of 120 mL of liquid, and 70 mL out of the right breast (Fig. 2). No foul odor was noted. The necrotic tissue and drained abscess contents were analyzed for the presence of gram-positive bacteria, gram-negative bacteria, anaerobic bacteria, and myco- bacteria. An infection caused by gram-positive bacteria was assumed, and empiric vancomycin (2 g/day, CJ CheilJedang Corp.) was administered while waiting

Peptococcus Infection after Breast Augmentation Using Autologous Fat InjectionSang Gue Gang, Joung Ki Kim, Syeo Young Wee, Chul Han Kim, Min Sung TarkDepartment of Plastic and Reconstructive Surgery, Soonchunhyang University College of Medicine, Seoul, Korea

Correspondence: Sang Gue GangDepartment of Plastic and Reconstructive Surgery, Soonchunhyang University College of Medicine, 59 Daesagwan-ro, Yongsan-gu, Seoul 140-743, KoreaTel: +82-2-709-9283, Fax: +82-2-796-3543 E-mail: ksps1108@hanmail.net

No potential conflict of interest relevant to this article was reported.

Received: 30 Jun 2012 • Revised: 31 Jul 2012 • Accepted: 13 Aug 2012 pISSN: 2234-6163 • eISSN: 2234-6171http://dx.doi.org/10.5999/aps.2012.39.6.669 • Arch Plast Surg 2012;39:669-671

Copyright 2012 The Korean Society of Plastic and Reconstructive SurgeonsThis is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/3.0/) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

Autologous fat is widely used in reconstructive and aesthetic surgery [1]. Autologous fat insertion after a large amount of liposuction is possible, and autologous adipose injection has been widely used to restore dead spaces, correct scars, and improve facial or torso aesthetic contours. However, there is ongoing discussion regarding the advisability of such surgery because the outcome of such a procedure is influenced by the method of fat collection, the amount of injected fat, the sites of fat collection and injection, and other unknown factors. The general complications associated with this sur- gery include edema, hematoma, infection due to fat necrosis or local reaction to the foreign substance, cyst formation, and irregular shape of the recipient site. Of these complications, the development of infection at the recipient site deserves the most attention. Abscess formation and in severe cases, sepsis, can threaten a patient’s life [2]. We report a case of anaerobic infec- tion that developed after breast augmentation surgery using autologous fat extracted from both the upper arms and abdomen. A 39-year-old woman underwent autologous fat

Fig. 1. Preoperative photographic findings. Both breasts were swollen and the left breast showed cellulitic change with redness.

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Fig. 2. Intraoperative photographic findings. Drainage of a pus-like discharge with

necrotic tissue.

for the results of the culture and a consultation from an infectious disease specialist. The anaerobic bacterium, Peptococcus, was detected after 5 days of culture. Antibiotic treatment was continued until the 10th day of hospitalization. A follow-up blood test at that time showed normal levels of CRP (0.20 mg/dL), ESR (23 mm/hr), and WBC count (7,200 cells/µL). The patient’s condition im- proved, and we discontinued antibiotic treatment based on the consultation from the infectious disease specialist. The patient recovered fully. No complications such as recurrent infection or breast shape alteration were noted during follow-up. Symmetry and projection of the breasts were maintained. The patient was satisfied with her breast contour. Autologous fat is considered an ideal material for expanding tissue because, unlike artificial implants, it is not associated with hypersensitivity or foreign body reactions. Autologous fat injection of the breasts is used for various purposes such as to correct imbalanced or protruding parts of the breasts. Autologous fat may also be used to reconstruct small defects that occur after breast cancer resection, shrinking of soft tissue following radiation treatment, or nipple reconstruction [3]. Complications such as fat tissue necrosis, scleroma, tiny calcifications, shape alteration or surface irregu- larity due to fat tissue absorption, and infection may occur. However, the most serious complication is the occurrence of infection. The inflammatory response of the recipient breast tissue to the transplanted fat can cause necrosis. Abscess formation is possible, and severe sepsis can be life threatening [2]. Bacteria that are commonly known to cause acute infections are Staphylococcus aureus (S. aureus), S. epidermidis, and S. pyogenes. All of these bacteria are

sensitive to vancomycin; therefore, we empirically administered this antibiotic agent in this case. During emergency abscess drainage, a clear, oily discharge was first observed, followed by the yellow discharge of necrotic fat, and finally, a sticky, foamy discharge. The infected fat tissue was necrotic, and because it was surrounded by a belt of native fat, the abscess most likely formed from the inside. Interestingly, the bacterial culture obtained from the patient showed the presence of Peptococcus, which usually has a low pathogenicity and does not generally cause post-sur- gical infection. Peptostreptococcus is a genus of anaerobic, gram-positive, non-spore forming bacteria. The cells are small, spherical, and can occur in short chains, in pairs, or individually [4]. However, Peptostreptococcus is considered an important pathogen in the etiology of mixed anaerobic infections, and is usually absent or present in low numbers in the plaque of healthy individuals. We presumed that a synergistic infection was caused by a pathogenic aerobic gram-positive bacterium that is more frequently associated with post-surgical infections [5]; therefore, we continued the empiric treatment with vancomycin that targeted methicillin-resistant S. aureus after consulting with an infectious disease specialist. Because all of the signs and symptoms of infection improved within 10 days of incision and drainage along with vancomycin treat- ment, no additional antibiotic agent to specifically target anaerobic bacteria was administered. The technique employed for collecting and injecting the fat is extremely important for a successful autolo- gous fat transplantation. To reduce the possibility of complications, exposure of the fat to air before trans- plantation and mechanical damage should be mini- mized. An appropriate site should be chosen for the extraction of fat, according to the amount of adipose

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tissue needed, in order to minimize exposure of the collected tissue to the surrounding environment. Exact guidelines for successful fat transplantation surgery have not yet been established. References

1. Bucky LP, Kanchwala SK. The role of autologous fat and alternative fillers in the aging face. Plast Reconstr Surg 2007;120:89S-97S.

2. Valdatta L, Thione A, Buoro M, et al. A case of life-threatening sepsis after breast augmentation by fat injection. Aesthetic Plast Surg 2001;25:347-9.

3. Gutowski KA; ASPS Fat Graft Task Force. Current applications and safety of autologous fat grafts: a report of the ASPS fat graft task force. Plast Reconstr Surg 2009;124:272-80.

4. Ryan KJ, Ray CG, Sherris J. Sherris medical micro- biology: an introduction to infectious diseases. 4th ed. New York: McGraw-Hill; 2004.

5. Brook I. The role of encapsulated anaerobic bacteria in synergistic infections. FEMS Microbiol Rev 1994; 13:65-74.

Recurrence of Nevus Lipomatosus Cutaneous Superficialis after CO2 Laser TreatmentYoung Joon Kim, Jung Hun Choi, Hoon Kim, Sang Hyun Nam, Young Woong ChoiDepartment of Plastic and Reconstructive Surgery, Sanggye Paik Hospital, Inje University College of Medicine, Seoul, Korea

Correspondence: Sang Hyun Nam Department of Plastic and Reconstructive Surgery, Sanggye Paik Hospital, Inje University College of Medicine, 1342 Dongil-ro, Nowon-gu, Seoul 139-707, Korea Tel: +82-2-950-1048, Fax: +82-2-932-6373E-mail: nsh1103@paik.ac.kr

No potential conflict of interest relevant to this article was reported.

Received: 10 Apr 2012 • Revised: 1 Jun 2012 • Accepted: 2 Jun 2012pISSN: 2234-6163 • eISSN: 2234-6171http://dx.doi.org/10.5999/aps.2012.39.6.671 • Arch Plast Surg 2012;39:671-673

Copyright 2012 The Korean Society of Plastic and Reconstructive SurgeonsThis is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/3.0/) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

Nevus lipomatosus cutaneous superficialis (NLCS) is a relatively rare benign malformation characterized

by ectopic deposition of mature adipose tissue in the collagen bundles of the dermis [1-4]. NLCS is clas- sified into two subtypes: the multiple (classical) type and solitary type [1-3]. The multiple type usually appears within the first two decades of life, most com- monly in the pelvic girdle region and consists of flesh-colored or yellow papules or nodules [3,4]. Also, its histopathological features are relatively uniform [3]. In contrast, the solitary type consists of a single nodular lesion without a favored location and it usually occurs in adults [3]. Surgical excision is a simple and adequate treatment for all lesions [2]. Recently, some authors have reported that CO2 laser is useful method of treat- ment for NLCS, especially in the multiple type [4]. We report here a case of multiple type NLCS on the right lower back, which recurred after CO2 laser treatment and was treated by staged surgical excisions. To the best of our knowledge, there have not been any cases of recurred NLCS after laser treatment in the literature. A 13-year-old girl presented with asymptomatic, yellow-orange papules on the right lower back measuring 14 × 5 cm and composed of three clusters (Fig. 1). According to her parents, the skin masses had appeared at age 5 and gradually increased in number and size as she grew. However, there was no evidence of any systemic disease and no symp- toms due to her back mass. Her family history was unremarkable, with a lack of similar skin lesions. Three years earlier, the patient had been treated with CO2 laser at another clinic to avoid the inconvenience of removing her clothes. At that time, they had thought that the mass was treated well. However, a few months

Fig. 1. Clinical photograph of the case. A 14×4 cm nevus lipomatosus cutaneous superficialis lesion on the right flank. Initially, only the central cluster had been presented, but after CO2 laser treatment, 2 more clusters were presented.

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