Fat Embolism after Surgery for Gynecomastia

Gynecomastia is a benign enlargement of the male breast, secondary to gland proliferation and is a common problem among the male population. Treatment is primarily surgical. The most common intraand postoperative complication is bleeding, followed by seroma, infection, insufficient results, inverted nipple and nipple necrosis. The embolism is one of the non-specific complications. A 24-year-old male was presented to the Surgery Department with a diagnosis unilateral gynecomastia. The operation proceeded without complication and around 10 hours later, the patient complained of weakness in all four limbs, later nausea, and vomiting and after full cardiopulmonary resuscitation, the patient died. The main reason for the patient's death was concluded to be a postoperative pulmonary thromboembolism and fat embolism was discovered. In addition, there was a papillary carcinoma of the thyroid, which was missed before. We reported that unilateral gynecomastia associated with papillary carcinoma of the thyroid detected rarely at autopsy and fat embolism after surgery for gynecomastia is a rare complication.


Introduction
Gynecomastia is a benign enlargement of the male breast, secondary to gland proliferation (1).It is a common problem among the male population with a reported prevalence of up to 36%.Various treatment techniques have been described, but none has gained universal acceptance (2).Treatment is primarily surgical.The most common complication is bleeding, followed by seroma, infection, insufficient results, inverted nipple and nipple necrosis (3).The embolism is one of the non-specific complications (4).We reported that unilateral gynecomastia associated with papillary carcinoma of the thyroid detected rarely at autopsy and fat embolism after surgery for gynecomastia is a rare complication.

Case Report
A 24-year-old male was presented to the One-Day Surgery Department with a diagnosis "Unilateral gynecomastia".After
Corresponding Author: Grozeva Maria Forensic Medicine Department, Lozenetz Hospital, Sofia, Bulgaria E-mail: mgrozevabg@yahoo.comAfter the fat embolism was discovered.In addition, there was a papillary carcinoma of the thyroid, which was missed before.It was accepted the fat embolism was the reason for the patient's death.manifestations of paraneoplastic syndrome are ectopic secretion of hormones and tendency to embolism.The development of these disorders does not necessarily correlate with a cancer stage or prognosis (5)(6).
The main complications after breast surgery can divided into two groups: some general, non-specific complications (wound infections, seroma formation, hematoma) and specific, breast-related procedures (7).Venous thromboembolism (VTE), which includes both deep venous thrombosis and pulmonary embolism, is an important cause of morbidity and mortality in patients with cancer (8).The estimated annual incidence of a first episode of VTE in the general population is 0.117% (9).Patients with cancer have a 4-fold increased risk of VTE, for an annual incidence of approximately 0.48% (10).
In a recent survey in the United Kingdom, of 126 surgeons performing breast surgery, 38 surgeons (30%) did not routinely administer thromboprophylaxis.The estimated incidence of VTE after breast surgery in that survey was less than 1% (11).
The general risk factors for thromboembolic events in adults, i d e n t i f i e d f r e q u e n t l y i n l i t e r a t u r e a s v e n o s t a s i s , hypercoagulability, vessel wall inflammation (Virchow's triad), recent surgery or trauma, and malignancy, can be applied to children as well.Other risk factors, such as obesity, smoking, oestrogen therapy, prolonged bed rest, inherited disorders of coagulation and previous pulmonary embolism, are also wella c c e p t e d i n l i t e r a t u r e a s k n o w n r i s k f a c t o r s f o r thromboembolic complications.In addition, according to a small number of studies, hypogonadism, risperidone and testosterone injections also seem to be related with the incidence of deep venous thrombosis and pulmonary embolism (12)(13)(14)(15).JR Piggott and co-authors reported a case of bilateral pulmonary emboli after bilateral mastectomy in a 15year-old boy with gynecomastia and hypogonadism.
Furthermore, regarding all risk factors described so far, they also reported that BMI greater than 35 kg/m2 was the main risk factor for a thromboembolic event in patients undergoing body contouring procedures (16).The fat embolism syndrome was first described by Von Bergmann, who cared for a man with a broken femur and symptoms of the syndrome in 1873 (17)(18).Fat embolism mainly seem to occur after long bone fracture or a large area of soft tissue injury with the majority of cases being fat embolism of lung and occasional cases being combined embolisms of lung and brain as well.The onset of symptoms appears shortly after the injury or surgery.Lipid droplets can be observed within small pulmonary vessels and verified by special staining (19).
Fat embolism syndrome is an often-overlooked cause of breathlessness.The clinical background, chronology of symptoms and corroborative laboratory findings are

Discussion
Gynecomastia is a relatively common disease.
Subcutaneous mastectomy is performed on symptomatic patients and on those desiring cosmetic changes (1).The most common complication is bleeding, followed by seroma, infection, insufficient results, inverted nipple and nipple necrosis (3).The embolism is one of the non-specific complications.An explanation for the fat embolism could be the peculiarities of the breast's blood supply.The thoracic internal vein has perforative branches, which connect venous blood flows directly from the mummeries into the lungs (4).
Because of the patient's papillary carcinoma of the thyroid, it is possible that the patient had paraneoplastic syndrome.
all standard examinations he underwent surgery under , general anesthesia.During the operation a tumor fibrosis formation (50 mm) was found on the right breast.The following operations were performed: subcutaneous excision of the parenchyma and fat tissue and drainage.The excised tissue was sent for histological examination.The operation proceeded without complication.The patient recovered from anesthesia, and when alert, showed no signs of respiratory distress and was communicating comfortably.Around 10 hours later, the patient complained of weakness in all four limbs.He had nausea and vomiting.The patient was psychomotor aroused and slightly disorientated, with the arterial pressure 110/60 mm/Hg and pulse 100 per minute.A consultation with the neurologist and the anesthesiologist was implemented.The patient's neurological status was normal, without any pathological findings.The specialists concluded that it was a hysterical attack.Thirty minutes later, the upper half of the patient's body suddenly turned blue and he lost consciousness.There was no heartbeat and breathing.After full cardiopulmonary resuscitation, the patient died.The main reason for the patient's death was concluded to be a postoperative pulmonary thromboembolism at the autopsy.
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Typically, paraneoplastic syndromes are detected in patients after a cancer diagnosis.Paraneoplastic syndrome manifests itself clinically with concomitant tumours.It is usually in breast tumours, lungs, ovarian tumours, etc.The most common