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questions pratiques de l'université montréal > Sein > Flashcards

Sein Flashcards

1
Q

Define polymastia

A

presence of any accessory breast tissue

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2
Q

Define polythelia

A

supernumerary or accessory nipple

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3
Q

Define amazia

A

Absence of breast tissue (NAC present)

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4
Q

Define athelia

A

complete absence of NAC

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5
Q

Define amastia

A

Absence of breast tissue and NAC

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6
Q

Describe the Tanner stages

A

1 - Elevation of nipple; no palpable glandular tissue; no areolar pigmentation
2 - glandular tissue in subareolar region; nipple and breast project as single mound
3 - enlargement of breast but contour of breast and nipple in single stage
4 - enlargement of areola; increased areolar pigmentation; elevation of NAC above breast
5 - final smooth contour with no projection of the NAC

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7
Q

Which hormones stimulate breast development in adolescence

A

GnRh
Estrogen
Progesterone

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8
Q

Which homones affect breast development in adulthood

A

Estrogen
Progesterone
Prolactin
Placental lactogene (only during pregnancy)

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9
Q

Normal NAC size

A

38-45mm

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10
Q

Normal notch-to-nipple and nipple-to-IMF distance

A

Notch-to-nipple: 21cm
Nipple-to-IMF: 6.9cm

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11
Q

Name the 5 parenchymal vessels of the breast

A

Internal mammary
Thoracodorsal
Thoracoacromial
Intercostal
Lateral thoracic

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12
Q

What causes breast hypertrophy during pregnancy

A

Increased response to estrogen

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13
Q

what is the pathophysiology of hypermastia

A

Abnormal excessive growth in response to circulating estrogens

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14
Q

What is the Septum of Wuringer

A

Septum containing vascularization and nerve bundle to NAC. Originates in pectoral fascia along 5th rib

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15
Q

What are the limits of the breast

A

2nd rib
Sternum
IMF (6th rib)
Mid-anterior axillary line

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16
Q

What is the anatomical cause of ptosis

A

Attenuation of Cooper’s ligament

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17
Q

What are the 3 levels of axillary lymph nodes

A

I - lateral to the lateral border of pectoralis minor
II - underneath and posterior to pectoralis minor
III - medial to medial border of pectoralis minor

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18
Q

What are Rotter’s ganglions

A

Ganglions located between the pectoralis major and minor muscles

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19
Q

What are the 5 groups of axillary nodes

A

Apical axillary
Central axillary
Subscapular
Supra-clavicular
Pectoral

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20
Q

What is the origin of pectoralis MAJOR

A

Medial clavivle
Sternum
Ribs 2-6
External oblique
Rectus abdominus

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21
Q

What is the insertion of pectoralis MAJOR

A

Proximal head of humerus
Lateral portion of clavicle

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22
Q

What is the function of pectoralis MAJOR

A

Adduction and internal rotation of the arm

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23
Q

What is the innvervation of pectoralis MAJOR

A

Medial pectoral nerve (Sternal head)
Lateral pectoral nerve (Clavicular head)

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24
Q

What artery supplies the pectoralis MAJOR

A

Internal mammary **
Thoracoacromial**
Intercostal perforators
Lateral thoracic

** main ones

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25
Q

Describe the origin of pectoralis MINOR

A

Ribs 3-6 (anterolateral)

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26
Q

Describe the insertion of pectoralis MINOR

A

Coronoid process of scapula

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27
Q

What is the function of pectoralis MINOR

A

Draws scapula down and forward

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28
Q

What is the innervation of pectoralis MINOR

A

Medial pectoral nerve

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29
Q

What is the arterial supply of pectoralis MINOR

A

Pectoral branch of thoracoacromial a.
Lateral thoracic artery
Direct branch of axillary artery

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30
Q

Describe the origin of serratus anterior

A

Anterolateral aspect of upper 8 ribs

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31
Q

Describe the insertion of serratus anterior

A

Anterior surface of medial aspect of scapula

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32
Q

What is the function of serratus anterior

A

Stabilize scapula against chest wall during abduction and elevation of arm (pulls scapula forward and laterally)

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33
Q

What is the arterial supply of serratus anterior

A

Lateral thoracic artery
Branches of thoracodorsal artery

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34
Q

What is the innervation of the serratus anterior

A

Long thoracic nerve

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35
Q

What is the etiology of polythelia

A

Failiure of regression of mammary ridge remenents

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36
Q

What is the most common anomaly of the pediatric breast

A

Polythelia

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37
Q

What is the most common location of polyTHELIA

A

Inferior to the normal breast (around the IMF)

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38
Q

What is the treatment for polythelia

A

Observation
Surgical resection

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39
Q

What other systems should you investigate in the context of polymastia

A

Kidneys (renal u/s)
Thorax (chest XR)
Urogenital

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40
Q

What is the most common location of polyMASTIA

A

Lower axilla

41
Q

What is the pathogenesis of polymastia

A

Hormonal stimulation of residual mammary ridge tissue

42
Q

What is the preferred treatment for polymastia

A

Surgical excision once breast development is complete (direct excision vs liposuction)

43
Q

List complications that can occur from polymastia correction

A

seroma
incomplete excision
damage to intercostal nerves
painful scar
over agressive resection

44
Q

What syndromes can be associated with amastia

A

Poland syndrome
Rothschild syndrome
Choanal atresia-athelia syndrome
Scalp-ear-nipple syndrome

45
Q

What is the etiology of amastia

A

Failure of development of ectoderm and appendages

46
Q

What is the preferred treatment for athelia

A

NAC reconstruction following usual NAC reconstruction principles

47
Q

What is the preferred treatment for amastia and amazia

A

Breast mound reconstruction with expander and implant

Expander can go in prior to full maturity but implant need to wait until breast are fully developed

48
Q

What workup should you consider in an adolescent with abnormal breast development

A

hypothyroidism (TSH)
ovarian failure (Add)
androgen excess (testosterone)
connective tissue disorder (Add)
mitral valve prolapse (u/s)
prior radiation

49
Q

Describe the embryological development of the breast

A

Week 4- Mammary ridge from ectoderm

Week 7-8 -invagination of chest wall ectoderm in mesenchyme

Week12-16 - differentiation into smooth muscles and NAC

Week 20 - secondary mammary glands and cooper ligament

Week 20-32 - canalization

Week 32-40 - differentiation of parenchyma, lactiferous duct open, Eversion of nipple.

50
Q

What is Cooper’s ligament

A

Fibrous bands from deep fascia to the skin (attenuation -> ptosis)

51
Q

Symptoms/Signs of hypermastia (5)

A

Back and neck pain
Shoulder grooving
Chronic headaches
Numbness upper extremity (ulnar)
Intertrigo/rash/maceration

52
Q

What is + define glgantomastia

A

Juvenile virginal hypertrophy of the breast
At least 1800g per breast is removed
Onset with first menses

53
Q

What is the greatest risk factor for recurrence of glgantomastia

A

preganancy

54
Q

Goals of breast reduction surgery (6)

A

Improve symptoms
Decrease breast volume
Reposition NAC in correct position
Maintain vascularity to the NAC
Tension-free closure
Minimize scaring

55
Q

Benefits (3) and disadvantages (2) of breast suction lipectomy

A

Benefits:
- smaller scars
- preserves NAC vascularity
-preserves lactation

Disadavantages:
-flat breast
-tendency for ptosis

56
Q

Describe the vascular supply to the superior breast pedicle

A
  • Descending artery from the internal mammary
  • Located at 2nd interspace
  • Lies in subcutaneous tissue
57
Q

Up to which volume and which transposition can be achieved with a superomedial pedicle for breast reduction

A

2000g and 15cm transposition

58
Q

Describe the vascular supply to the medial breast pedicle

A
  • Branch from internal mammary
  • Located in 3rd interspace
  • Curves around medial aspect of the breast
59
Q

Describe the vascular supply to the lateral breast pedicle

A
  • Superficial branch from lateral thoracic
  • Lies laterally in subcetaneous tissues
60
Q

Describe the vascular supply to the inferior and posterior breast pedicle

A
  • deep branches perforating branches from the intercostal system
  • Located at the 4th interspace
  • additional supply form 5th interspace
61
Q

Cutoff that causes bulky inferior pedicles

A

nipple to IMF: 18cm

62
Q

Advantages of lower breast pedicle

A

Improvement of pressure sensation to breast skin and NAC

63
Q

Name for the vertical and horizontal bipedicle technique

When are they useful?

A
  • McKissock : Vertical
  • Strömbeck : Horizontal

Useful for secondary breast reduction

64
Q

4 types of skin resection patterns for breast reduction

A

Inverted T pattern
Vertical pattern
Circumareolar pattern
No vertical scar pattern (periareolar or inframammary)

65
Q

Advantages and disadavantages of inverted T breast reduction

A

Adv: allows removal of larrge area of skin
Diasv: More scaring

66
Q

Indication for circumareolar pattern breast reduction

A

Pstosis <2cm

67
Q

Disadavantages of circumareolar breast reduction

A

widdens NAC

68
Q

Advantages and disadavantages of vertical breast reduction

A

Adv: eliminates horizontal scar
Disv: 10-15% dog ear revision

69
Q

Describe the innervation of the breast

A

Intercostal nerves 3-6
Supraclavicular branches from cervical plexus (C3-C6)
Antero-medial branches from 3rd-5th intercostals

70
Q

Indications (5) of free nipple grafting

A

Nipple to IMF >18cm in patient that wants a small volume

> 35-40cm SN :N

Significant systemic disease that impairs blood flow

Patient with previous breast operation or chest wall radiation that impairs blood flow

Short anesthesia time required

71
Q

Disdavantage of free nipple grafting (4)

A

Depigmentation

Loss of sensation

Loss of lactation potential

Poor projection

72
Q

Avantages et désavantages de la liposuccion comme technique de réduction mammaire?

A

+ : Cicatrices minimes, préservation du NAC (vascularisation et innervation), préserve la lactation, peu de dérangement du support du sein

  • : Seins plats, pas de correction de la ptose, vêtements de support x6 semaines
73
Q

Rates of breastfeeding potential after breast reduction

A

Depends on source
50-70%
Higher rate of success if inferior pedicle
Higher rate of success if a column of breast parenchyma from nipple to chest wall is preserved

74
Q

4 façons de déterminer la position du NAC?

A

Pitanguy (transposition de l’IMF)
Mid-huméral, 1-2cm sous
Mesure directe from sternal notch, 19-21cm
8-10cm from superior breast border

75
Q

Steps for making breast reduction with wise pattern

A

1) Upright position
2) Midline
3) IMF +/- rebord superieur du sein
3) Breast meridian (midclavicular, 6cm from sternal notch down towards nipple)
4) Vertical nipple position (Pitanguy or 21cm sternal notch to meridian or 8-10cm from superior breast border and 10cm from midline)
5) Measure bilateral to ensure symmetry
6) Mark wise pattern (2cm above nipple position), vertical limbs 6cm
7) Draw pedicle ideally 8cm width

76
Q

Principes de Hall-Findlay pour la réduction mammaire secondaire?

A

Respect de l’apport sanguin aléatoire

Ne pas réélever le NAC significativement

nlever l’excès de tissus dans le pole inférieur avec un wedge orienté de façon vertical

Ne pas enlever de peau sous l’incision de l’IMF

Lipo = Aide important

77
Q

What is the recommendation for breast pedicle in a secondary (repeat) breast reduction of unknown initial pedicle?

A

free nipple graft or inferior wedge resection

78
Q

6 Post-op complication of breast reduction in radiated breast

A

Seroma
Fat necrosis
Nipple necrosis
Wound dehiscence
Cellulitis
Asymmetry

79
Q

True or false, drains after breast reduction lower complications/hematoma rates

A

False

80
Q

What to do if nipple turns blue during breast reduction

A

During dissection:
-Stop dissection
-Ensure adequate BP, urine output, temperature
-Observe for 10-15 minutes
-Convert to free nipple graft

During closure:
-Reopen and inspect
-Evacuate hematoma
-check for pedicle kinking
-Ensure adequate BP
-Convert to free nipple graft
-Rechauffer

81
Q

Name complications of breast reduction and % for the most common ones

A

NAC compromise 4-7%
Altered nipple sensation 9-25%
Unsatisfactory scarring 4%
Wound healing complications 19%
Inability to breastfeed
Fat necrosis
Asymmetry
Insufficient reduction or overreduction
Infection
Change of shape over time

82
Q

Quand obtenir une mammographie dans le contexte de réduction mammaire?

A

Selon les recommandations de dépistage normal (à partir de 50ans ad 74ans q2-3ans si faible risque, q1an après néo du sein, centre dédié avec radiologiste expérimenté si greffe graisseuse)

Avant la chirurgie selon recommandations et 6 mois après la chirurgie puis reprendre normalement le screening

83
Q

Risque de trouver une néoplasie dans un spécimen de BBR?

A

1% en général
Si procédure balancing, 5%

84
Q

Advantages of alloderm in breast reconstruction

A

stabilise positionnement implant
decreases capsular contracture rate
decrease implant rippling
decrease animation deformity
decrease radiotx effects

85
Q

3 inconvénient de l’alloderme dans la reconstruction du sein

A

increased risk of seroma
red breast syndrome
cost

86
Q

BIA-ALCL: when to suspect, diagnosis

A

Texturd breast implant
Late conset peri-implant seroma
Dx: cytological evaluation: CD30+, ALK - of implant capsule and seroma fluid

87
Q

Treatment ALCL

A

ADD

88
Q

4 avantages de la IMA dans la reconstruction du sein

A

-Bon match de diamètre
-accès facile
-lambeau peut être placé médial
-évite dissection près de l’aisselle
(risque lymphoedeme, lésion plexus, etc)

89
Q

4 inconvénient de la IMA comme vaisseaux receveur

A

Veine G plus petite
Difficile à travailler avec rythme respi
Perte de l’IMA pour futur pontage
Risque pneumothorax

90
Q

4 inconvénient de l’artère thoraco-dorsal comme vaisseaux receveur

A

-peut avoir été endommagée par chx
-flap doit être placé plus latéral
-nécessité de plus de dissection axillaire (et ses risques)
-positionnement + difficile pour micro

91
Q

Contre-indication au DIEP

A

ATCD d’abdominoplastie
ATCD demCCK ouverte (Kocher incision)

92
Q

Contre-indication à la reconstruction du sein autologue

A

maladie métastatique non contrôlée
commorbidités sévères

93
Q

Contre-indication à la reconstruction pré-pectorale

A
  • maladie Inflammatoire
  • Stade 4
  • Métastases axillaires
  • Doute sur viabilité lambeaux
  • Tumeur sur la peau ou le pectoralis
  • DB2 non contrôlé
  • IMC >40
  • ATCD radiotx
94
Q

Inconvénient d’un SIEA p/r à DIEP

A
  • Pédicule plus court
  • Pastille perfusée plus petite
  • Présence inconstante
  • Prône au vasospasme
  • Plus risque sérome
95
Q

Décrire les 4 landmarks du footprint du sein

A

Latéral: 1-2cm derrière ligne axillaire antérieure

Médial: 1-2cm du midline sternal

Inf: IMF

Sup: courbe connectant lignes médial et latéral, dont l’apex est en mid-claviculaire

96
Q

nommer les 3 composantes principales dans la définition du sein
(importants à considérer dans la reconstruction du sein)

A

Footprint du sein
Tissus mous
Enveloppe cutanée

97
Q

a/n de quelle côte se trouve le plis infra-mammaire

A

5 ou 6

98
Q

5 caractéristique du sein chez un massive weight loss patient

A

Déflation
Ptose grade 3
Médialisation du NAC
Perte courbe du sein latéral
Rouleau thorax latéral

99
Q

3 changements du sein post-ménaupause

A

Perte d’élasticité de la peau
Atrophie glande
Prise de poids / gravité

questions pratiques de l'université montréal (41 decks)

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