Breast Reduction Flashcards
A 44-year-old woman, gravida 4, para 3, is evaluated because of symptomatic macromastia. Bilateral reduction mammaplasty is planned. The patient’s mother was diagnosed with postmenopausal breast cancer at 53 years of age; the patient underwent genetic testing which was negative for BRCA mutation. Physical examination shows the patient wears a size 32F brassiere and has grade III ptosis, shoulder grooving, dense breast tissue without palpable masses or nipple discharge, and intertrigo. According to current American Cancer Society recommendations, which of the following breast imaging methods should be used before the planned reduction mammaplasty in this patient?
A) Diagnostic mammography
B) MRI
C) Screening mammography
D) Thermography
E) Ultrasonography
The correct response is Option C.
The American Society of Plastic Surgeons participates in the Choosing Wisely campaign, which advocates for evidence-based guidelines in determining diagnostic and therapeutic interventions.
The American College of Surgeons’ recommendations for breast cancer screening in average-risk, asymptomatic women are for an opportunity for a baseline mammogram at 40 to 44 years of age, annual screening from 45 to 54 years of age, and biennial screening for women older than 55 years of age who are in good health and have a life expectancy of at least ten years.
This patient is asymptomatic, and is not a BRCA carrier, and meets criteria for a screening mammogram.
A diagnostic mammogram is performed to evaluate abnormalities found on screening mammogram, in the context of breast cancer history, or with physical exam findings such as a breast mass, nipple discharge, or breast pain.
MRI is recommended as an adjunct to mammography in the case of a known BRCA mutation, if the first-degree relative is known to have the BRCA mutation but the patient is untested, or if there is a lifetime risk of 20 to 25% of breast cancer.
Thermography uses an infrared camera to show patterns of blood flow and heat on the surface of the breast. It is not a replacement for mammography, not recommended as part of screening protocols, and is not associated currently with any quality studies that demonstrate that it can be used effectively as a screening tool for breast cancer.
Ultrasonography is also used as an adjunct to screening mammography.
It is important to note that different societies have different recommendations on timing of screening mammography. The ACS recommends screening at 45 years of age, the American College of Radiology recommends screening starting at 40 years of age, and the USPSTF recommends biennial mammograms between 50 and 74 years of age.
2018
In a Wise-pattern reduction mammaplasty using the superior medial pedicle, sensation is provided to the nipple-areola complex by which of the following nerves?
A) Lateral cutaneous branch of the fourth intercostal nerve
B) Lateral cutaneous branch of the second intercostal nerve
C) Medial pectoral nerve
D) Terminal branches of the fourth and fifth anterior intercostal nerves
E) Terminal branches of the second and third anterior intercostal nerves
The correct response is Option D.
The nipple-areola complex is innervated by the lateral cutaneous branch of the fourth intercostal nerve as well as the terminal branches of the fourth and fifth anterior intercostal nerves. However, when a superior medial pedicle in a reduction mammaplasty is used, the contribution from the lateral branch of the fourth intercostal nerve is excised. The lateral cutaneous branch of the second intercostal nerve is also known as the intercostobrachial nerve, which provides sensation to the medial and posterior upper arm. The medial pectoral nerve innervates portions of the pectoralis major and minor.
2018
A 43-year-old woman comes to the office for consultation for reduction mammaplasty. She wears a DDD brassiere and wants her brassiere size to be decreased to a C cup. Current medications include oral contraceptive pills. She does not smoke cigarettes. Height is 5 ft 5 in (167 cm) and weight is 145 lb (65.7 kg). BMI is 23.8 kg/m2. Physical examination shows the suprasternal notch to nipple distance is 29 cm and inframammary fold to nipple distance is 16 cm. Regardless of technique, which of the following factors is most likely to result in an increased risk for postoperative fat necrosis in this patient?
A) Massive weight loss
B) Oral contraceptive use
C) Patient age
D) Suprasternal notch to nipple distance
E) Tissue resection weight
The correct response is Option E.
Fat necrosis is one of the more common complications associated with reduction mammaplasty. Regardless of technique, the rates of fat necrosis have been reported in the 2 to 10% range. Fat necrosis presents as firm, soft-tissue masses that usually resolve spontaneously. It can be associated with redness and mild discomfort and may be confused with an infectious process. The literature is inconsistent with respect to detailed cause and effect or definitive correlations between fat necrosis and risk factors. However, some are generally agreed upon as significant and are mostly consistent in studies. Some of these risk factors for the development of fat necrosis include greater BMI, larger resection weights (both absolute and controlled for preoperative breast size), and long suprasternal notch to nipple distance (especially over 37 cm). Other factors that less clearly affect the rate of fat necrosis are smoking and the surgical technique employed.
Multiple studies have demonstrated increased risk of fat necrosis with greater obesity.
Although there have been some studies that suggest a correlation between fat necrosis and age, the studies have not reached a consensus nor have they shown statistical significance when evaluated in a controlled fashion. One study by Shermak et al. looked specifically at age-related risks and was not able to find a significant correlation with fat necrosis. There have been no studies or associations found to link exogenous hormone therapy or oral contraceptive use to increased fat necrosis. Alternatively, there has been some evidence to suggest that hormone supplementation might decrease the rate of infectious complications. The rate of fat necrosis and complication in general increases with longer suprasternal notch to nipple distances, most notably greater than 37 cm.
Massive weight loss is not associated with an increased risk for fat necrosis in the breast.
2018
Compared with reduction mammaplasty excisional techniques, which of the following is characteristic of liposuction-only reduction mammaplasty?
A) Does not typically impair breast-feeding potential
B) More effectively treats ptosis
C) Poses a higher risk to the blood supply of the nipple-areola complex
D) Results in a higher incidence of impaired sensation to the nipple-areola complex
E) Results in minimal swelling postoperatively
The correct response is Option A.
Liposuction-only reduction mammaplasty does not involve the use of a pedicle to ensure blood supply to the nipple. The nature of liposuction involves leaving major vessels and nerves intact and therefore does not pose an increased risk for blood supply loss to the nipple-areola complex. In addition, sensation to the breast as well as to the nipple-areola complex is not typically impaired following liposuction-only reduction mammaplasty. For similar reasons, breast-feeding potential is not typically compromised. The recovery from liposuction-only reduction mammaplasty can be quite significant, and it can take about 6 weeks for bruising and swelling to decrease and about 6 months for the breast to soften and for lumpiness to settle. Liposuction-only reduction mammaplasty does not work well when breast tissue is mostly glandular and thus has limited usefulness in those patients in whom it may seem most desirable, such as teenagers. Liposuction-only reduction mammaplasty does not more effectively treat ptosis.
2017
A healthy 42-year-old woman undergoes bilateral reduction mammaplasty for symptomatic breast hypertrophy. Pathologic analysis of one of the tissue specimens shows ductal carcinoma in situ. Which of the following percentages best represents the incidence of this finding in a reduction mammaplasty specimen?
A) 1%
B) 7%
C) 10%
D) 12%
E) 25%
The correct response is Option A.
The histologic finding is consistent with a diagnosis of ductal carcinoma in situ (DCIS). The incidence of occult breast cancer in reduction mammaplasty specimens most closely approximates 1%. Invasive ductal carcinoma is the most common malignant lesion identified, but DCIS, lobular carcinoma in situ, Paget disease, and fibrosarcoma have also been reported less frequently. All breast tissue removed from women older than 40 years should be sent to pathology for microscopic analysis.
2017
A 30-year-old woman with symptomatic macromastia is scheduled for a Wise pattern breast reduction. Which of the following postoperative complications is most likely in this patient?
A) Delayed wound healing
B) Fat necrosis
C) Hematoma
D) Hypertrophic scarring
E) Tear-drop deformity of the nipple-areola complex
The correct response is Option A.
In the 2005 prospective, multicenter trial of 179 patients by Cunningham, Gear, Kerrigan and Collins, reduction mammaplasty had an overall complication rate of 43%. The most common complication was delayed wound healing (21.6%), followed by spitting sutures (9.2%), hematoma (3.7%), nipple necrosis (3.6%), hypertrophic scars (2.5%), fat necrosis (1.8%), seroma (1.2%), and infection (1.2%).
Delayed wound healing correlated directly with average preoperative breast volume, average resection weight per breast, and smoking; and inversely with patient age. In this study, vertical techniques had a higher overall rate of complications.
In the Stevens, et al. report of their 11-year experience with outpatient breast reduction, delayed wound healing was also the most common complication.
2017
A healthy 27-year-old woman is evaluated 16 weeks after bilateral reduction mammaplasty with an inferior pedicle technique. Histologic examination of the resected tissue shows no malignancy. She reports a tender mass in the right breast that she noted 8 weeks after operation. She is now apprehensive because her mother had breast cancer at age 34. Physical examination of the affected breast shows a palpable, slightly tender, discrete, firm 2-cm subcutaneous mass beneath the upper areolar border. Examination shows no skin dimpling, nipple retraction, erythema, or edema. Which of the following is the most appropriate next step in management?
A) Conduct needle aspiration of the lesion
B) Inject triamcinolone acetonide suspension 20 mg into the mass
C) Proceed to surgery for removal of the mass
D) Refer the patient for an oncology consultation
E) Schedule ultrasonography and mammography of the affected breast
The correct response is Option E.
Postsurgical changes in the breast after reduction mammaplasty encompass a variety of physical and radiographic manifestations. On presentation of a breast mass after reduction mammaplasty, a diagnostic protocol is used to determine whether operative intervention is appropriate, to avert unnecessary biopsy and to avoid overlooking breast malignancy. Fat necrosis, oil cysts, fibrosis, organizing hematoma, calcifications and, rarely, concurrent malignancy should be considered in this patient. In the absence of acute phenomena characteristic of a wound infection, work-up should consist of mammography and ultrasonography of the affected breast. Combining the radiographic findings with echographic appearance of the mass will help to differentiate fat necrosis and other benign conditions from the more ominous malignant etiology. The mammographic appearance of fat necrosis ranges from completely undetectable to a spiculated density and clustered microcalcifications. Many authors believe that the calcifications of fat necrosis can be distinguished from those seen with breast malignancies. Ultrasonographic findings include a solitary cyst, heterogenous echogenicity, and microcalcifications. Any remaining doubt as to the biologic nature of the mass should then be pursued with needle or open biopsy of the mass. Injection of any agent into the mass before it is definitively diagnosed is contraindicated, as is surgical removal or observation without obtaining a confident exclusion of malignancy. Referral to an oncologist would be premature in this instance and would provoke an unnecessary level of patient anxiety.
2016
A 56-year-old woman undergoes bilateral reduction mammaplasty. Eight hundred grams per breast is removed and sent to permanent pathology. Which of the following results most likely requires further discussion with a breast surgeon?
A) Apocrine metaplasia
B) Atypical lobular hyperplasia
C) Fibroadenoma
D) Papillomatosis
E) Sclerosing adenosis
The correct response is Option B.
All of the answers are examples of benign breast disease. However, atypical lobular hyperplasia (ALH) is associated with an increased risk for breast cancer. Depending on other patient risk factors, chemoprevention with anti-estrogen medications and increased surveillance may be recommended.
2016
A 47-year-old woman undergoes bilateral reduction mammaplasty surgery. Pathologic analysis of the resected breast tissue shows atypical ductal hyperplasia in the left breast. Which of the following is the most appropriate next step in management?
A) Gail model risk assessment
B) Hormonal therapy with aromatase inhibitors
C) Hormonal therapy with selective estrogen receptor modulators
D) Left-sided mastectomy
E) Postoperative radiation therapy
The correct response is Option A.
Atypical ductal hyperplasia is a risk factor for breast cancer in both the ipsilateral and contralateral breast, although the risk for the ipsilateral breast is higher. There is an approximately three-fold to five-fold increase in the risk for breast cancer in patients who have had biopsy-proven atypia. In an excisional biopsy, no additional surgery is needed for a finding of atypia; this is in distinction to atypia found on core biopsy, in which excision is recommended. In neither case is mastectomy indicated.
Radiation therapy is indicated for positive surgical margins in breast cancer excision, tumor size greater than 5 cm, more than four positive axillary nodes, and T4 disease.
The finding in this scenario should prompt the practitioner to perform a full risk assessment. Although the Gail model has been criticized for underestimating the risk for cancer in the context of atypical hyperplasia, it is still the most appropriate choice of the options listed. If the risk for breast cancer is sufficiently high after all factors are considered, hormonal therapy as a preventive measure may be indicated.
2016
A 45-year-old woman, gravida 3, para 3, undergoes reduction mammaplasty. Pathologic examination of excised tissue shows a completely excised, 1-cm papilloma. Which of the following is the most appropriate next step in management?
A) External radiation therapy
B) Mammography
C) Sentinel lymph node biopsy
D) Subcutaneous mastectomy
E) Tamoxifen therapy
The correct response is Option B.
The management of papillomas found on breast core needle biopsy specimens is controversial. The concern is malignancy, and some institutions have reported false-negative rates in biopsy. The presence of atypia is an indication for complete excision, and is also associated with a final upstaging to in situ or invasive carcinoma. For these reasons, excisional biopsy is recommended for lesions found on core needle biopsy. In this case, the lesion was completely excised, which is the most aggressive treatment. Because the final pathology was benign disease, this excision is adequate.
A subcutaneous mastectomy is not necessary, and a sentinel lymph node biopsy is not indicated because the pathology is benign. Similarly, tamoxifen treatment and external radiation therapy are not indicated for this benign condition.
2016
A 45-year-old woman comes to the office because she is interested in having reduction mammaplasty. She asks if undergoing reduction mammaplasty would decrease her risk of breast cancer. Which of the following is the most appropriate response to this patient?
A) The rate of breast cancer has been shown to be slightly increased in patients who undergo reduction mammaplasty
B) Reduction mammaplasty appears to decrease the rate by 90%
C) Reduction mammaplasty decreases the rate of breast cancer but less than prophylactic mastectomies
D) There is no evidence that reduction mammaplasty decreases cancer risk
The correct response is Option C.
Over the past decade, several large retrospective studies have looked at the rate of developing breast cancer after reduction mammaplasty. The breast cancer rates in patients undergoing reduction mammaplasty have consistently been decreased by about 30%. This differs from prophylactic mastectomy, which lowers the rate by as much as 90%.
2015
An otherwise healthy 17-year-old nulliparous girl is evaluated because of significant breast asymmetry. She has noted an increase in the size of her left breast over the past 2 months. Current medication includes a combined oral contraceptive. The patient undergoes mammography and biopsy. Pathologic examination of excised tissue shows a benign phyllodes tumor. Which of the following is the most appropriate next step in management?
A) Enucleation
B) Mastectomy with sentinel lymph node biopsy
C) Progestin-only oral contraceptive
D) Tamoxifen followed by lumpectomy
E) Wide local excision
The correct response is Option E.
The three most common causes for adolescent unilateral breast enlargement are giant fibroadenoma, phyllodes tumor (previously called cystosarcoma phyllodes), and juvenile breast hypertrophy. Differentiation between phyllodes tumor and giant fibroadenoma on core needle biopsy is difficult. Phyllodes tumors are fibroepithelial tumors and stromal derived. The stromal component can appear similar to a fibroadenoma, and this similarity can make the two difficult to distinguish; in some cases, the stromal component resembles a soft-tissue sarcoma. Core needle biopsy is performed for diagnosis, and phyllodes tumors typically have increased cellularity, mitosis, and stromal overgrowth when compared with fibroadenomas.
Phyllodes tumors of the breast represent approximately 3% of breast neoplasms. They are classified as benign, borderline, or malignant. Wide excision with 1-cm margins is recommended for all classifications. The extent of resection is determined by the grade, and the grade is associated with the risk of local recurrence.
Margin-negative, breast-conserving therapy is appropriate for benign phyllodes tumors. Malignant phyllodes tumors behave more similarly to sarcomas than to other types of breast cancer. Although there is controversy about the role of radiation therapy, this modality is less effective than surgery, and is reserved for margin-positive, malignant tumors. Chemotherapy is not indicated in this patient. The greatest risk with benign phyllodes tumors is local recurrence, and overall, the prognosis of these tumors is considered excellent.
The only known condition associated with the development of phyllodes tumors is Li-Fraumeni syndrome.
2015
A 16-year-old girl comes to the office with her parents because she would like reduction mammaplasty surgery. Height is 5 ft 1 in (155 cm) and weight is 160 lb (72.6 kg). She wears a size 36G brassiere and her breast size has remained the same for the past year. She has significant physical manifestations of macromastia. Her parents report that she does not want to go to work or school because she is embarrassed by the size of her breasts. Which of the following is the most appropriate management of this patient’s condition?
A) Defer reduction mammaplasty until the patient has lost at least 20 lb (9.1 kg)
B) Defer reduction mammaplasty until the patient is at least 22 years of age
C) Perform reduction mammaplasty
D) Refuse to perform surgery until the patient is evaluated by a psychiatrist
The correct response is Option C.
Breast hypertrophy can affect girls as young as 10 to 15 years old and can result in massive breast development that can have profound physical and psychological impact on the patient. Reduction mammaplasty is indicated for these patients, despite the risk of breast growth postoperatively, which may necessitate a secondary operation. As long as the patient has a mature attitude, understands the permanence of the scars involved, and has parents who are supportive of her decision, then surgery should not be delayed simply to wait until the patient reaches a certain age. The large breasts are already a major problem and further growth will compound the problem and make it difficult to manage later.
With the rise in childhood obesity, there has been an increase in the number of patients seeking adolescent reduction mammaplasty. The cause of macromastia in pubertal and parapubertal girls is variable and includes endocrine changes, childhood obesity, and juvenile (virginal) hypertrophy of the breast. Benefits of reduction mammaplasty include resolution of pain, improved quality of life, extroversion, and emotional stability.
Reduction mammaplasty has been clearly proven to decrease the physical manifestations associated with macromastia, regardless of height and weight, as well as provide psychosocial benefits and improve self-esteem, regardless of age of patient.
2015
Reduction mammaplasty using which of the following pedicles has the greatest risk of altered nipple sensation?
A) Inferior
B) Inferocentral
C) Lateral
D) Superior
E) Superomedial
The correct response is Option D.
Reduction mammaplasty with a superior pedicle that involves resection of the tissue at the base of the breast is associated with a higher risk of injury to the nerve branches that innervate the nipple-areolar complex. Innervation from the lateral cutaneous branches runs deep within the pectoral fascia before sharply turning in an anterior direction to innervate the nipple from its deep aspect.
The lateral pedicle, inferior pedicle, and inferocentral pedicle save the tissue containing the lateral cutaneous branches, decreasing the chance for injury to this nerve and reduced nipple sensation. The superomedial pedicle preserves the anterior cutaneous branches which run superficially from the medial aspect of the breast, and also provide sensation to the nipple. The superior pedicle resects both the medial and lateral innervations to the nipple.
2015
An otherwise healthy 44-year-old woman comes to the office for reduction mammaplasty consultation. She wears a size 44DD brassiere. Physical examination shows rashes underneath the breasts, shoulder grooving from brassiere straps, and shoulder pain. A reduction is planned with removal of 500g of tissue bilaterally. The woman reveals that her sister underwent reduction mammaplasty with a much larger resection size and questions whether she will have the same relief of symptoms. Which of the following is the most appropriate response?
A) Larger reductions are associated with less marked relief of symptoms
B) Larger reductions are associated with more marked relief of symptoms
C) Smaller reductions are associated with less marked relief of symptoms
D) Smaller reductions are associated with more marked relief of symptoms
E) Resection size is not associated with relief of symptoms
The correct response is Option E.
The ASPS has a clinical guideline summary on reduction mammaplasty, based on the available evidence. Although insurance companies often use resection weight as a criterion for coverage, resection weight is not necessarily associated with relief of symptoms; thus, predictions of relief of symptoms must be made based on the individual clinical picture. This evidence is graded B.
The risk of complications, however, does increase with resection weight (Grade B evidence). This risk of complications must be weighed against the potential for relief of symptoms with large resection weights. A distinction is made between resection weight and BMI. The ASPS guideline found only “inconclusive” data on the association between BMI and the risk of complications.
2014
A 45-year-old woman with macromastia presents for breast reduction surgery. BMI is 34 kg/m2. Physical examination shows grade III ptosis with bilateral bra strap grooving. A photograph is shown. Breast reduction mammaplasty of approximately 1000 g per breast using a Wise pattern and inferior pedicle technique is planned. Which of the following factors is most likely to increase this patient’s risk for perioperative complications?
A) BMI
B) Degree of ptosis
C) Inferior pedicle
D) Resection volume
E) Wise pattern
The correct response is Option D.
According to the Breast Reduction Assessment: Value and Outcomes (BRAVO) study, the overall complication rate for breast reduction was 43% with delayed healing as the most common. This complication was correlated directly with average preoperative breast volume, average resection weight/breast, and smoking, and was correlated inversely with age. Analysis associated resection weight as the sole variable for increased risk of complications and with absolute number of complications (greater than 847 g). Each 10-fold increase in resection weight increased the risk of complication 4.8 times and increased the risk of delayed healing 11.6 times. Degree of ptosis was not correlated with delayed healing. Vertical incision techniques were associated with an increased complication frequency without a link to specific complications.
2021
A 15-year-old girl is referred to the office because of a 7-month history of asymptomatic, rapid enlargement of the right breast. Physical examination shows a large, palpable mass occupying the lower half of the right breast. There is marked nipple-areola complex stretching and prominent dilated veins. Photographs are shown. Mammogram and ultrasound show a dense, circumscribed, homogeneous 15-cm mass in the right breast. Which of the following is the most likely diagnosis?
A) Carcinoma
B) Cyst
C) Giant fibroadenoma
D) Juvenile breast hypertrophy
E) Phyllodes tumor
The correct response is Option C.
This patient has a fibroadenoma, the most common breast neoplasm in adolescent females. Giant fibroadenoma are typically solitary, firm, nontender, and present as a rapid asymmetric breast enlargement with prominent overlying veins and occasional pressure-induced skin ulceration. These lesions are larger than 5 cm and present at or soon after the onset of puberty. These lesions are typically treated with enucleation using breast reduction techniques for optimal symmetry with the contralateral breast. Mastectomy is not indicated, and no other adjuvant therapy is necessary. Smaller fibroadenomas may be watched conservatively, with minimal risk for malignant transformation. Surgical intervention is indicated in cases of mastodynia, neck/back pain secondary to large size, difficulty with clothing due to asymmetry, and to alleviate patient concern.
The differential diagnosis would include phyllodes tumor, breast hypertrophy, or cystic enlargement. Carcinoma would be unlikely in this age demographic. Phyllodes tumors are large, benign tumors that typically occur in the perimenopausal patient. They are histologically distinct from fibroadenomas, and transformation of a fibroadenoma to a phyllodes tumor is exceptionally rare.
Juvenile breast hypertrophy may present as unilateral or bilateral breast enlargement. The enlargement is diffuse without evidence of a discrete mass or nodularity. Juvenile breast hypertrophy typically presents in early puberty, rarely regresses spontaneously, and is much more severe than simple breast hypertrophy. The underlying cause is attributed to estrogen stimulation at the onset of the first menses. Treatment is reduction mammoplasty.
2022
