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Flashcards in Breast Reduction Deck (101):
1

A 38-year-old woman, gravida 2, para 2, is scheduled to undergo reduction mammaplasty because of pain in the neck and shoulders. She wears a size 44E brassiere. Physical examination shows pendulous breasts. The sternal notch-to-nipple distance is 40 cm. Hypertrophy of which of the following muscles is most likely in this patient?
A)Latissimus dorsi
B) Levator scapulae
C) Pectoralis major
D) Rhomboid major
E) Trapezius

E) Trapezius

In mammary hypertrophy, the downward pull of the breasts rotates the shoulders forward, requiring significantly more work of the shoulder girdle muscles. It is the unique function of the trapezius to square the shoulders that makes it most vulnerable in mammary hypertrophy; because of the extra work this requires, it often becomes hypertrophic. Patients often complain of shoulder, neck, and upper back pain as aresult of the trapezius strain

2

Actions of the Trapezius muscle

The trapezius elevates the scapula in squaring the shoulders, and the superior, middle, and inferior fibers act together to pull the scapulae posteriorly, bracing the shoulders.

3

Actions of the latissimus

The latissimus extends, adducts, and medially rotates the humerus.

4

Actions of the levator scapulae

The levator scapulae elevate the scapula and rotate the glenoid cavity inferiorly

5

Actions of the rhomboid major and minor

The rhomboid major and minor together retract the scapula and fix the scapula to the thoracic wall.

6

Most vulnerable muscle in mammary hypertrophy

In mammary hypertrophy, the downward pull of the breasts rotates the shoulders forward, requiring significantly more work of the shoulder girdle muscles. It is the unique function of the trapezius to square the shoulders that makes it most vulnerable in mammary hypertrophy; because of the extra work this requires, it often becomes hypertrophic. Patients often complain of shoulder, neck, and upper back pain as aresult of the trapezius strain

7

A 25-year-old woman is scheduled to undergo breast reduction with resection of 2.4 lb (1100 g) from each breast. Current weight is 200 lb (91 kg), and height is 5 ft 8 in (173 cm). Physical examination shows macromastia with nipple-sternal notch distance of 34cm on the left and 35 cm on the right. A photograph is shown. Which of the following postoperative complications is most likely in this patient?
A)Bleeding
B) Fat necrosis
C) Infection
D) Seroma
E) Wound breakdown

E) Wound breakdown

Wound healing complications are more likely to occur following breast reduction in a young, healthy, but obese patient with large resection volumes. Other complications might occur but are less common. None of the other complications have been associated with risk factors.

8

Risks associated with breast reduction

Common risks associated with breast reduction include infection, symptomatic scar, seroma, wound healing complications, fat necrosis, asymmetry, and need for reoperation. BMI, volume of breast tissue resection greater than 1000 g per breast, and tobacco use are thegreatest risk factors for complication following surgery.

9

A 43-year-old woman is undergoing bilateral reduction mammaplasty with the inferior pedicle technique. The dermis is preserved during de-epithelialization of the pedicle to protect which of the following anatomical structures?
A) Perforators from the internal mammary artery
B) Perforators from the lateral thoracic artery
C) Sebaceous glands
D) Subdermal plexus
E) Superficial layer of the superficial fascia of the breast

D) Subdermal plexus

10

The major blood supply to the breast comes from:

The major blood supply to the breast comes from perforating branchesof the internal mammary artery, lateral branches of the posterior intercostal arteries, and branches of the axillary artery.

11

Blood supply to the breast: the axillary artery branches

The blood supply from the axillary artery includes the pectoral branches, the highest thoracic artery, and the lateral thoracic artery. Those vessels from the pectoral branches enter underneath the muscle before coming through it to supply the breast tissue. The vessels from the lateral thoracic artery, known as the lateral mammary branches, wrap around the lateral border of the pectoralis muscle to supply the lateral breast.

12

Blood supply to the breast: the internal mammary artery branches

The second, third, and fourth perforating branches from the internal mammary artery, known as the medial mammary arteries, enter the medial aspect of the breast.

13

Blood supply to the breast: the intercostal arteries

The perforating branches from the second, third, and fourth posterior intercostal arteries, known as the mammary branches, enter the breast laterally.

14

Overal locations of the blood vessels of the breast

The vascular arcades seem to be concentrated at the periphery of the breast (the cutaneoglandular plexus), and the larger vessels appear to lie not far beneath the skin, superficial to the glandular tissue.

This finding has led certain authors to conclude that resection of the gland should not commence fewer than 2 to 3 cm from the chest wall; if skin flaps are elevated, they should be kept at least 2 cm thick for maximum viability. This also justifies preservation of the dermis when deepithelializing flaps to protect the subdermal plexus from injury.

15

What supplies the breast parenchyma?

Perforators from the internal mammary artery and lateral thoracic artery supply the breast parenchyma.

16

Which of the following arteries is the dominant blood supply to the nipple-areola complex?
A) Axillary
B) Internal mammary
C) Subclavian
D) Superficial epigastric
E) Thoracodorsal

B) Internal mammary

17

The nipple-areola complex receives its blood supply from:

The nipple-areola complex receives its blood supply from the mammary arteries, which are a branch of the subclavian artery.

18

A 16-year-old girl is referred by her pediatrician for mammaplasty because of breast hypertrophy that has worsened during the past 2 years. She wears a size 36DD brassiere and has constant pain in the shoulders and back due to the weight of her breasts. Menarche occurred at 10 years of age. Height is 5 ft 4 in (163 cm), and weight is 165 lb (75 kg). Physical examination shows breast hypertrophy, shoulder grooving, intertrigo dermatitis, and striae. An abnormality of which of the following is the most likely cause of this patient's condition?
A) End-organ responsiveness to estrogen
B) Number of estrogen receptors
C) Progesterone concentration
D) Prolactin concentration
E) Serum estrogen concentration

A) End-organ responsiveness to estrogen

19

Mammary hypertrophy: predominant factor leading to the condition

Abnormal end-organ responsiveness to estrogen is the predominant factor leading to breast hypertrophy.

20

Mammary hypertrophy: hormone levels

It has been demonstrated that normal levels of estrogen, progesterone, and prolactin exist in patients with breast hypertrophy.

21

Mammary hypertrophy: number of estrogen receptors

These patients have a normal number of estrogen receptors.

22

A 33-year-old woman comesto the office because of a new lump in her right breast 6 weeks after undergoing bilateral reduction mammaplasty using the inferior pedicle technique. Preoperative examination of the breasts showed no abnormalities. Current examination shows a hard, nontender mass in the lateral aspect of the upper right breast. Which of the following is the most likely diagnosis?
A ) Abscess
B ) Fat necrosis
C ) Fibroadenoma
D ) Hematoma
E ) Seroma

B ) Fat necrosis

A patient presenting with a hard, nontender lump 6 weeks after reduction mammaplasty is most likely to have fat necrosis. This is usually the result of vascular compromise to areas of the parenchyma associated with hemorrhagic necrosis.

An abscess or hematoma would be firm but likely tender. Fibroadenoma would not likely be palpable so early postoperatively. However, if the lump does not resolve within a few weeks, CT scan or ultrasonography should be considered to rule out malignancy. Seroma would most likely have a softer consistency.

23

Cause of fat necrosis

Postoperative fat necrosis after breast reduction is usually the result of vascular compromise to areas of the parenchyma associated with hemorrhagic necrosis.

24

Management of fat necrosis

Small areas of fat necrosis can be managed conservatively, and secondary revision can be performed after a period of 6 months to 1 year. If skin and fat necrosis is extensive and associated with an infection, surgical debridement and antibiotics are required.

25

An otherwise healthy 33-year-old woman comes to the office because of back pain, brassiere grooving, and an inframammary rash. She wears a size 42 L brassiere. She has one child and says she would like to have more children. BMI is 33 kg/m2. The distance from nipple to sternal notch is 37 cm bilaterally, and the distance from nipple to inframammary fold is 16 cm bilaterally. A photograph is shown. Which of the following is the most appropriate reduction mammaplasty technique for this patient?
A ) Inferior pedicle with Wise skin pattern
B ) Lower pole amputation with nipple grafting
C ) Medial pedicle with vertical skin pattern
D ) Superior pedicle with vertical skin pattern
E ) Superior pedicle with Wise skin pattern and nipple grafting

A ) Inferior pedicle with Wise skin pattern

The patient described is a young, healthy woman, who may desire to have more children later in life, making nipple preservation an optimal choice. She is large in size and has ptosis, making an inferior pedicle with Wise pattern the best technique to ensure adequate tissue removal.
This technique is also able to reduce the vertical dimension of the breast, which is more challenging with vertical skin pattern reduction mammaplasty. Inferior pedicle reduction mammaplasty can achieve significant reduction in breast volume and alleviate preoperative symptoms with a low risk of complications.

Limited incision techniques might fail to achieve reliable reduction in breast volume and result in aesthetic dimensions as well. These vertical scar techniques are best reserved for smaller volume reductions.

26

A 37-year-old woman obtains a baseline postoperative mammogram six months after undergoing reduction mammaplasty. The presence of which of the following calcifications is most likely to cause the plastic surgeon to order additional evaluation?
A ) Branching
B ) Dystrophic
C ) Eggshell
D ) Popcorn-like
E ) Rod-like

A ) Branching

27

Calcifications can be grouped into three categories:

Calcifications can be grouped into three categories: malignant, indeterminate, or benign.

28

Appearance of malignant vs benign breast calcifications

Malignant calcifications can appear as casting (linear and branching) or pleomorphic (granular).

Benign calcifications have many appearances and include popcorn-like (fibroadenoma), large rod-like (secretory), round eggshell (oil cysts), and dystrophic or coarse (fat necrosis).

29

When is tissue biopsy indicated postoperatively with discovery of calcification

Tissue biopsy is recommended for calcifications that are determined to be indeterminate or malignant

30

A 26-year-old woman is scheduled to undergo reduction mammaplasty. In designing the pedicles for the procedure, which of the following arteries is the predominant blood supply to the breast?
A ) Internal thoracic
B ) Lateral thoracic
C ) Supreme thoracic
D ) Thoracoacromial
E ) Thoracodorsal

A ) Internal thoracic

31

The internal mammary artery is also called..

Internal thoracic artery

32

Predominant blood supply to the breast vs other supplies

Perforating branches off of the internal thoracic artery (also called the internal mammary artery) are the predominant blood supply to the breast. The lateral thoracic and thoracoacromial arteries also contribute to the bloodsupply of the breast but to a lesser degree.

33

Which of the following is the main disadvantage of reduction mammaplasty by liposuction alone?
(A)Dissemination of occult cancer
(B)Inability to breast-feed
(C)Inadequate correction of ptosis
(D)Increased hematoma formation
(E)Persistence of back pain

(C)Inadequate correction of ptosis

34

Advantages/disadvantages of liposuction breast reduction

The primary advantage of this technique is the lack of scars. Several authors cite rapid return to work and exercise, decreased operative time, normal sensation, and full ability to breast-feed. Complications such as hematoma, seroma, and nipple necrosis are minimal compared to incisional techniques, and reductions of one to two cup sizes are reported. Symptoms of macromastia are relieved. Authors warn that this technique is not effective in young patients with dense breast tissue and little fatty tissue.

Disadvantages of this technique include difficulty assessing the amount of breast tissue removed because of the infiltration of tumescent solution, lack of pathologic examination, inadequate tissue removal in large reductions, and poor skin shrinkage.

35

The preferred candidate for liposuction-only breast reduction

The preferred candidate for liposuction-only reduction is described as a young patient with good skin elasticity, minimal to moderate hypertrophy, and no ptosis.

36

What happens to the position of the nipples with liposuction breast reduction

Although nipples will rise somewhat with liposuction, the average elevation is 2 to 6 cm, and patients still have nipples which are at or below the inframammary fold (first-or second-degree ptosis).

37

For reduction mammaplasty, which of the following is the greatest advantage of a vertical procedure over an inverted-T method?
(A)Decreased risk of hematoma
(B)Greater ability to breast-feed
(C)Increased sensation of the nipple
(D)Initial natural shape of the breast
(E)Smaller scar

(E)Smaller scar

38

Vertical mammaplasty

Vertical mammaplasty is a technique that uses adjustable markings, an upperpedicle for the areola, and a central breast reduction with decreased undermining of the skin. Key features of the vertical scar reduction mammaplasty include skin excision in only one direction, which reduces scar burden, and central vertical glandular excision, which contributes to improved postoperative shape by narrowing the breast while maximizing projection as a result of suturing the medial and lateral pillars together. There is no wide periareolar skin excision; therefore, circumareolar scar quality is not compromised by excess tension

39

Difficulties with the vertical mammary reduction

However, this method is more intuitive and inherently less precise than the inverted-T method. Because of the central and posterior nature of glandular resection in vertical mammaplasty, it is more difficult to determine the end point of resection

40

Complications of vertical scar technique vs wise pattern

A recent study comparing vertical mammary reduction with the Wise pattern technique showed no statistical differences in the rate of hematomas and nipple numbness. Breast-feeding is possible with either technique but may require supplementation with formula. The initial shape in a vertical mammaplasty is poor; it has a flattened lower pole, and dog-ears are frequently present. This improves after three to six months, although small revisions are sometimes necessary

41

Which of the following is the estimated incidence of detection of occult breast cancer during reduction mammaplasty?
(A)0.002%
(B)0.02%
(C)0.2%
(D)2%
(E)20%

(C)0.2%

42

The average risk of occult breast cancer in patients undergoing breast reduction

The average risk of occult breast cancer in patients undergoing breast reduction has been estimated to be 0.27%

Cancer is often found at the in situ or early stages.

43

A 38-year-old woman comes to the office for consultation regarding reduction mammaplasty. She currently wears a size 36DD brassiere and wants to be able to wear a C cup brassiere postoperatively. Height is 5 ft 6 in and weight is 120 lb. On physical examination, the distance from nipple to sternal notch is 35 cm. Selection of a vertical mammaplasty technique in this patient is limited by which of the following?
(A)Desired postoperative cup size
(B)Fat content of the breasts
(C)Lateral positioning of the nipples
(D)Length of the pedicle
(E)Preoperative cup size

(D)Length of the pedicle
The contraindications to performing a vertical reduction mammaplasty are the length ofthe pedicle and the amount and quality of the remaining skin. Blood supply to the nipple may be compromised in a very long pedicle. It is impossible to give a numeric value to this length. Lassus recommends a transposition of no more than 9 cm.

44

Contraindications to vertical reduction mammaplasty

The contraindications to performing a vertical reduction mammaplasty are the length of the pedicle (long) and the amount and quality of the remaining skin for a very large breast.

45

Limit of pedicle length for virtual reduction mammaplasty

The contraindications to performing a vertical reduction mammaplasty are the length ofthe pedicle and the amount and quality of the remaining skin. Blood supply to the nipple may be compromised in a very long pedicle. It is impossible to give a numeric value to this length. Lassus recommends a transposition of no more than 9 cm.

46

Vertical reduction mammoplasty and amount of resection

Vertical reduction mammaplasty more easily achieves consistently high-quality results when the method is applied to a small or moderate reduction (< 800 g per side). Although reductions of more than 1000 g are technically difficult to achieve, they are not impossible and have been reported by some centers. With the adjunct of the L-shaped scar, larger amounts of skin can be resected, limiting the need for postoperative revisions.

47

During a reduction mammaplasty procedure, preservation of sensation in the nipple-areola complex is most dependent on which of the following?
(A)Amount of tissue resected
(B)Nipple-to-notch distance
(C)Pedicle location
(D)Preoperative breast volume
(E)Skin incision used

(C)Pedicle location

The most important determinant in preserving sensation in the nipple-areola complex is the anatomic location of glandular resection.

Preoperative breast volume is a factor in preoperative nipple-areola sensation (ie, the sensitivity of the nipple-areola decreases as the breast volume increases). However, preoperative breast volume, type of skin incision used, or nipple-to-notch distance have not been found to be the most important factor in preservation of nipple sensation.

48

Most important determinant in preserving nipple-areolar sensation of reduction mammaplasty

The most important determinant in preserving sensation in the nipple-areola complex is the anatomic location of glandular resection

49

High risk vs low risk pedicles for preserving nerve sensation to the nipple-areolar complex

Superior glandular pedicle techniques with tissue resections at the base of the breast are associated with higher risk of injury to the nerve supply. Lateral, inferior, and medial-based pedicles allow for better preservation of the nerve supply.

50

The amount of tissue resected vs nipple sensation in reduction mammoplasty

The amount of tissue resected has not been shown to have a statistically significant effect on preservation of sensation in the nipple-areola complex.

51

A 38-year-old woman has severe congestion and edema of the left nipple-areola complex four hours after undergoing bilateral reduction mammaplasty. Examination shows rapid capillary refill. Which of the following surgical interventions is the most appropriate initial management?
(A) Debridement and healing by second intention
(B) Release of the suture line and exploration of the pedicle
(C) Conversion of the nipple-areola complex to a free composite graft
(D) Central wedge resection under the nipple-areola complex
(E)Removal of additional tissue from the breast

(B) Release of the suture line and exploration of the pedicle

Loss of the nipple-areola complex after reduction mammaplasty may be caused by torsion of the pedicle or by excessive tension on the closure. In the first hours after reduction mammaplasty, attempted exploration of the pedicle should be performed to release any possible tension. A blue and engorged nipple may be the first sign of impending necrosis. Other methods such as use of nitroglycerin patch may aid vasodilatation of the vessels.

52

Management of signs of impending necrosis of the nipple-areola complex immediately postoperatively for reduction mammaplasty

Loss of the nipple-areola complex after reduction mammaplasty may be caused by torsion of the pedicle or by excessive tension on the closure. In the first hours after reduction mammaplasty, attempted exploration of the pedicle should be performed to release any possible tension. A blue and engorged nipple may be the first sign of impending necrosis. Other methods such as use of nitroglycerin patch may aid vasodilatation of the vessels.

Conversion of the pedicle/nipple-areola complex to a free composite graft should be considered if release of the pedicle does not yield any improvement in the blood flow or if no correctable cause can be identified.

53

A 15-year-old girl comes to the office with a six-month history of sudden, rapid, asymmetric enlargement of her left breast. On physical examination, there is a large palpable mass occupying the left breast, which also has marked nipple-areola stretching, prominent dilated veins, and skin ulceration superolateral to the nipple. Mammograms and sonograms show a dense, circumscribed, 6-cm-diameter homogeneous mass occupying the left breast. Which of the following is the most likely diagnosis?
(A) Carcinoma
(B) Cyst
(C) Giant fibroadenoma
(D) Juvenile breast hypertrophy
(E) Phyllodes tumor

(C) Giant fibroadenoma

The differential diagnosis of a large lesion in the breast of an adolescent girl includes giant fibroadenoma, phyllodes tumor, and virginal hypertrophy. Fibroadenoma is the most common breast neoplasm in the adolescent patient, and giant fibroadenoma is characterized by size greater than 5.0 cm in diameter, presentation at or soon after puberty, and short doubling time.

54

Most common breast neoplasm in the adolescent patient

Fibroadenoma is the most common breast neoplasm in the adolescent patient.

55

Giant fibroadenoma

Giant fibroadenoma is characterized by size greater than 5.0 cm in diameter, presentation at or soon after puberty, and short doubling time. he lesion is usually solitary, firm, and nontender and presents as a rapid asymmetric breast enlargement with prominent veins over the tumor and occasional skin ulceration due to pressure. Giant fibroadenomas are benign lesions that can be excised by enucleation with minimal risk of local recurrence.

56

Phyllodes tumor

Phyllodes tumors are large, benign tumors that occur primarily in the perimenopausal patient.

57

Juvenile breast hypertrophy

Juvenile breast hypertrophy is a rare but well-described entity in young, early pubertal girls. It presents as diffuse enlargement of the breast without any nodularity or presence of a discrete mass. Management is reduction mammaplasty.

58

A 25-year-old woman comes to the office because she has loss of sensation in the nipple-areola complexes three months after she underwent bilateral reduction mammaplasty. Which of the following intercostal nerves were most likely injured during the procedure?
(A) First and second
(B) Third and fourth
(C) Fifth and sixth
(D) Seventh and eighth
(E) Ninth and tenth

(B) Third and fourth

59

In general, cutaneous branches of the intercostal nerves are noted to pass through the deep fascia of the chest wall at:

In general, cutaneous branches of the intercostal nerves are noted to pass through the deep fascia of the chest wall at two anatomic points: the lateral cutaneous branches at the midaxillary line and the anterior cutaneous branches beside the sternum.

60

The breast skin is innervated by:

The breast skin is innervated by the lateral and anterior cutaneous branches of the T1 through T7 intercostal nerves. However, the contributions of the T1 and T7 intercostal nerves are small, and thus the branches of the T2 through T6 intercostal nerves are likely more important.

61

Detailed innervation of the nipple-areola complex

Innervation to the nipple-areola complex is supplied by the anterior and lateral cutaneous branches of the T3 through T5 intercostal nerves. While all of these nerves supply branches, the T4 intercostal nerve is the most consistent in its contribution to innervation to the nipple-areola complex. Also, the cutaneous area of sensation of the nipple-areola complex, supplied by the T4 intercostal nerve branches, is larger than that supplied by the T3 or T5 intercostal nerve branches. Therefore, the T4 intercostal nerve is the primary nerve for cutaneous innervation to the nipple-areola complex, but it is not the sole supplier of this innervation.

62

On the basis of evaluation of cutaneous light-pressure thresholds of the breast with Semmes-Weinstein monofilaments, which of the following areas of the breast is most sensitive?
(A) Areola
(B) Inferior quadrants
(C) Nipple
(D) Superior quadrants

(C) Nipple

63

Parts of the breast that are sensitive/less sensitive

Irrespective of breast size, the skin in the superior quadrant is the most sensitive part of the breast, the areola is less sensitive, and thenipple is the least sensitive part to light pressure. The fact that the nipple is the least sensitive area in the female breast is thought to allow the mother to nurse without discomfort. Vibration is most sensitive in the areola.

64

Demographics vs breast sensitivity

Larger breasts are significantly less sensitive than smaller breasts in all anatomic areas, and there is a significant decrease of sensibility with increasing breast ptosis. Sensitivity tends to decrease with age.

65

A 15-year-old girl has a one-year history of asymmetric enlargement of the left breast. Physical examination shows a 10-cm mass as well as ptosis, marked stretching of the nipple-areola complex, skin ulceration superolateral to the nipple, and presence of a prominent, dilated vein. Mammography and ultrasonography show a dense, circumscribed, homogeneous mass occupying the entire breast. Which of the following is the most appropriate management?
(A) Enucleation of the mass
(B) Hormone therapy
(C) Lumpectomy and postoperative radiation therapy
(D) Reduction mammaplasty
(E) Total mastectomy and reconstruction

(A) Enucleation of the mass

66

Enucleation

Removal of a mass without cutting into or dissecting it

67

Differential of a large breast lesion in a female adolescent

A large breast lesion in a female adolescent may result from giant fibroadenoma, phyllodes tumor, and juvenile breast hypertrophy.

68

A 20-year-old woman who comes to the office for consultation regarding reduction mammaplasty inquires about ability to breast-feed aftersurgery. The most appropriate response to this patient is that breast-feeding is possible after each of the following techniques EXCEPT
(A) free nipple
(B) inferior pedicle
(C) liposuction
(D) McKissock bipedicle
(E) vertical

(A) free nipple

69

In patients who have undergone bilateral reduction mammaplasty using an inferior pedicle technique, which of the following findings is most likely to be identified on mammography six to 18 months after surgery?
(A) Calcifications
(B) Fat necrosis
(C) Oil cysts
(D) Periareolar fibrosis
(E) Skin thickening

(A) Calcifications

70

Findings on mammograms following breast reduction

One recent study, involving women who underwent bilateral reduction mammaplasty using an inferior pedicle technique, examined findings on radiographs of the breasts six to 18 months after surgery. According to the results of this study, the most common findings were
- 90% parenchymal redistribution
- 85% elevation of the nipple caused by a downward shifting of the breast tissue.
- 26% with Calcifications
- 20% retroareolar fibrotic banding from the transposed flap
- 19% w/ oil cysts resulting from localized fat necrosis

71

A 13-year-old boy with gynecomastia desires corrective surgery. An initial preoperative evaluation of this patient should include examination of which of the following?
(A) Eyes
(B) Thyroid gland
(C) Pectoralis muscle
(D) Abdomen
(E) Genitalia

(E) Genitalia

The genitalia should be examined in this 13-year-old boy with gynecomastia. Although most adolescent boys with breast development do not exhibit other signs of feminization caused by hormonal excess or other genetic problems,examination of the genitalia could reveal an underlying cause of the gynecomastia. Testicular tumors are typically palpable on physical examination, and some adolescent boys will have nonpalpable and/or undescended testes. In patients with these findings,genetic and/or endocrine evaluation is required before any operative procedures are performed.

72

A 35-year-old woman is scheduled to undergo reduction mammaplasty with removal of approximately 700 g of tissue bilaterally using an inferior pedicle technique. During preoperative marking of the patient, which of the following points should be used as a landmark to best determine the new position of the nipple?
(A) 7 cm above the inframammary fold
(B) 21 cm below the sternal notch
(C) Inframammary fold
(D) Midhumerus
(E) Xiphoid

(C) Inframammary fold

73

Determining the position of the nipple in patients undergoing reduction mammaplasty

In patients undergoing reduction mammaplasty, the new nipple position should be determined when the patient is in an upright position, before the procedure is performed. During preoperative marking, the inframammary fold is used as a landmark to determine the most appropriate position of the nipple on the midbreast line. This is consistent regardless of the reduction technique performed.

The measurement of 7 cm above the inframammary fold is essential during surgery, when the new nipple position is being marked during closure of the incisions, but is not a reliable preoperative measurement.

74

The sensation to the nipple-areolar complex is derived from the
(A) anterior cutaneous branches of the sixth and seventh intercostal nerves
(B) anterolateral branches of the third through fifth intercostal nerves
(C) branches of the lateral pectoral nerve
(D) nerves of the cervical plexus
(E) nerves traveling with the internal mammary artery

(B) anterolateral branches of the third through fifth intercostal nerves

75

A 16-year-old girl has had rapid, asymmetric enlargement of the left breast over the past year. On physical examination, an 18-cm mass can be palpated; there is ptosis and stretching of the nipple-areola complex. The veins are prominent and dilated, and there is ulceration of the skin superolateral to the nipple. Mammography shows a dense, circumscribed, homogeneous mass that encompasses the entire breast. Which of the following is the most appropriate management?
(A) Hormone therapy
(B) Enucleation
(C) Subcutaneous mastectomy
(D) Simple mastectomy
(E) Reduction mammaplasty

(B) Enucleation

76

Sensation to the nipple-areola complex is provided primarily by which of the following nerves?
(A) Anterior cutaneous nerve from T3
(B) Anterior cutaneous nerve from T4
(C) Lateral cutaneous nerve from T4
(D) Medial cutaneous nerve from T5
(E) Posterior cutaneous nerve from T5

(C) Lateral cutaneous nerve from T4

77

A 40-year-old woman has cyanosis of the right nipple one hour after undergoing bilateral breast reduction with removal of 1500 g of tissue on each side. Which ofthe following is the most appropriate management?
(A) Observation
(B) Application of leeches
(C) Hyperbaric oxygen therapy
(D) Release of the sutures
(E) Conversion of the nipple-areola complex to a split-thickness skin graft

(D) Release of the sutures

78

Gynecomastia is an adverse effect of administration of each of the following agents EXCEPT
(A) cimetidine (Tagamet)
(B) digitalis (Digoxin)
(C) minocycline (Minocin)
(D) spironolactone (Aldactone)
(E) zolpidem (Ambien)

(E) zolpidem (Ambien)

79

Which of the following is associated with reduction mammaplasty using the vertical scar (Lejour) technique?
(A) Central vertical glandular excision
(B) Inferiorly based blood supply to the nipple
(C) Keyhole-pattern skin excision
(D) Precision in determining the endpoint of resection
(E) Wide periareolar skin excision

(A) Central vertical glandular excision

80

Features of the vertical (Lejour) mammaplasty

Features of the vertical (Lejour) mammaplasty include central vertical glandular excision to improve postoperative shape (by narrowing the breast while maximizing breast projection) and excision of skin in one direction only to decrease scar burden. Vertical mammaplasty is a technique of central breast reduction with undermining of the lower skin, as well as use of adjustable markings and an upper pedicle to maintain the blood supply to the areola

81

What maintains blood supply to the areola during vertical mammaplasty

An upper pedicle maintains the blood supply to the areola

82

A 58-year-old man has had moderate gynecomastia with severe skin redundancy for the past eight years. A photograph is shown above (Grade III gynecomastia is characterized by marked breast enlargement with marked skin redundancy). Complete physical examination and laboratory studies show no other abnormalities. Which of the following is the LEAST acceptable technique for management?
(A) Suction lipectomy with subsequent skin shrinkage
(B) Concentric circle resection
(C) Wise-pattern mastopexy
(D) Glandular resection through an areolar incision with adjunctive suction lipectomy
(E) Breast amputation and free nipple grafting

(C) Wise-pattern mastopexy


The Wise-pattern mastopexy is used to create a projecting, conical breast in women undergoing breast reduction and should not be performed in gynecomastia patients who require a breast elimination procedure.
Suction lipectomy has eliminated the need for skin resection in many gynecomastia patients, especially adolescents. Fibrous enlargement can be managed with glandular resection through an areolar incision with adjunctive suction lipectomy. However, skin resection is still recommended in older patients with grade III gynecomastia who have significant ptosis.

83

Grade I gynecomastia

Grade I gynecomastia involves visible mild breast enlargement without skin redundancy.

84

Grade IIA gynecomastia

In grade IIA gynecomastia, there is moderate breast enlargement without skin redundancy;

85

Grade IIB gynecomasti

in grade IIB gynecomastia, there is moderate breast enlargement with skin redundancy.

86

Grade III gynecomastia

Grade III gynecomastia is characterized by marked breast enlargement with marked skin redundancy.

87

Why shouldn't the Wise pattern be used for male gynecomastia?

The Wise-pattern mastopexy is used to create a projecting, conical breast in women undergoing breast reduction and should not be performed in gynecomastia patients who require a breast elimination procedure

88

Which of the following long-term complications results in the greatest patient dissatisfaction following reduction mammaplasty?
(A) "Bottoming out" of the breasts
(B) Excessive reduction
(C) Inadequate reduction
(D) Loss of nipple sensation
(E) Prominent scarring

(E) Prominent scarring

89

What is the greatest source of patient dissatisfaction after reduction mammaplasty

Prominent scarring

90

A 30-year-old woman who underwent reduction mammaplasty using the inferior pedicle technique 10 years ago is pregnant with her first child. The probability that she will breast-feed is closest to
(A) 10%
(B) 30%
(C) 50%
(D) 70%
(E) 90%

(B) 30%

91

What percent of breast reduction patients can breast feed postoperatively?

~30%

92

A 62-year-old woman with a history of Stage III breast cancer is scheduled for delayed autologous breast reconstruction from the abdominal donor site. She has no other medical problems. BMI is 30 kg/m2. Her mother had a lower extremity deep venous thrombosis in the past. Caprini risk assessment score is 9. Which of the following is the most appropriate method of postoperative VTE risk reduction?
A) Aspirin therapy
B) Early ambulation after surgery
C) Low-molecular-weight heparin therapy
D) Sequential compression device use
E) No VTE prevention is indicated

C) Low-molecular-weight heparin therapy

Venous thromboembolism (VTE) is a disorder with short-term mortality and long-term morbidity. Plastic and reconstructive surgery patients are known to be at high risk for VTE after surgery. Symptomatic VTE occurs with high frequency after post-bariatric body contouring (7.7%), abdominoplasty (5%), and breast or upper body contouring (2.9%). To fully identify VTE risk in surgical patients, individualized patient assessment is advocated. The Caprini risk assessment model (RAM) is a useful and effective tool to stratify surgical patients for VTE risk. For patients with high Caprini scores, a significantly greater likelihood of VTE events is observed. Approximately 11% of patients with Caprini score >8 will have a VTE within 60 days after surgery.

Based upon recommendations from the ASPS VTE Task Force, patients undergoing elective plastic and reconstructive surgical procedures who have Caprini RAM score of 7 or more should have VTE risk reduction strategies employed, such as limiting operating room times, weight reduction, discontinuation of hormone replacement therapy, and early postoperative mobilization. Patients undergoing major plastic and reconstructive operative procedures performed during general anesthesia that last longer than 60 minutes should receive VTE prevention. For patients with Caprini score of 3 to 6, the use of postoperative low-molecular-weight heparin (LMWH) or unfractionated heparin (UH) should be considered. For patients with Caprini score of 3 or more, use of mechanical prophylaxis throughout the duration of chemical prophylaxis for non-ambulatory patients should be considered. For patients with Caprini score of 7 or more, the use of extended LMWH postoperative prophylaxis should be strongly considered.

Aspirin does not decrease the risk of VTE and may increase the risk of perioperative complications.

93

A 55-year-old woman comes to the office for a second opinion because she is displeased with the results of a recent bilateral mastectomy and breast reconstruction with 800-mL high-profile silicone implants. A photograph is shown. BMI is 35 kg/m2. She repeatedly shows pictures of models with augmented breasts and says that she wants her breasts to be “perkier.” She requests augmentation/mastopexy. Which of the following is the most appropriate next step in management?

A) Augmentation/mastopexy
B) Implant exchange
C) Mastopexy
D) Reassurance
E) Referral to a psychiatrist

D) Reassurance

The most reasonable approach in this patient is to offer reassurance and reset her expectations. A patient with a BMI of 35 kg/m2 who undergoes mastectomy and implant reconstruction will never look like a model with augmented breasts. This patient clearly has misguided expectations. Any surgical intervention is unlikely to produce the result she is looking for, when in fact she has a very acceptable result as is. Referral of this patient to a psychiatrist will likely upset the patient and undermine her trust.

94

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

E) Resection size is not associated with relief of symptoms

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.

95

Which of the following best describes the role of estrogen in breast function?
A) Decreases cell division
B) Decreases fibrocystic changes
C) Facilitates ductal growth
D) Facilitates glandular growth
E) Facilitates periductal stromal development

C) Facilitates ductal growth

Breast development is a complex interplay of multiple factors. Estrogen and progesterone play a significant role in breast development—not only at puberty, but also during and after pregnancy, and during and after menopause. In general, estrogen causes ductal proliferation, while progesterone causes glandular proliferations. Progesterone is similarly responsible for periductal stromal development. Estrogen increases, not decreases, cell division, and is also associated with increased, not decreased, fibrocystic changes.

96

A 5-ft 1-in (155-cm), 185-lb (84-kg), 45-year-old woman comes to the office for follow-up 1 week after she underwent reduction mammaplasty with a medial pedicle in the outpatient facility. BMI is 35 kg/m2. On examination, the right nipple-areola complex is dusky and cool. Nipple ischemia is suspected. Which of the following is the most appropriate next step in management?
A) Debridement of the necrotic nipple with primary closure
B) One-stage debridement of the necrotic nipple and reconstruction of the nipple-areola complex
C) One-stage exploration and conversion to a free nipple graft
D) Release of all insetting sutures
E) Observation only

E) Observation only

Partial or total nipple necrosis may be one of the most devastating complications of reduction mammaplasty. The incidence of compromise of the nipple-areola complex is typically less than 5% after breast reduction. Increased BMI is a risk factor for and increased risk of both nipple necrosis and wound healing complications. Reduction mammaplasty is frequently performed on an outpatient basis. Patients are seen within a week of surgery for wound checks, but this may be too late to address a nipple with vascular compromise.

If nipple ischemia is noted at the time of surgery during inset, stitches should be released and vascularity reevaluated. An objective assessment of blood flow can be aided with the use of fluorescein injection and a Woods lamp, or with newer screening modalities that are currently being evaluated for this purpose. While inset may be reattempted, the patient will likely require conversion to a free nipple graft. The nipple should be grafted to well-vascularized, deepithelialized dermis and not to ischemic fat that may be part of the compromised pedicle.

If nipple ischemia is detected in the early postoperative period, and there is no hematoma or issue with external compression, the nipple should be released from its inset position. This will relieve tension on the pedicle. If the nipple does not improve, the patient is taken back to the operating room for free nipple grafting.

If nipple ischemia is not identified in the early postoperative period, the patient should be treated with conservative wound care until healing is complete. Nipple reconstruction can then be undertaken in a delayed manner.

97

A 45-year-old woman comes to the office for consultation regarding reduction mammaplasty because of pain of the neck and upper back. She currently wears a size 42 DDD brassiere and would like to be a C cup. A vertical reduction mammaplasty with a superomedial pedicle is planned. Which of the following is the dominant blood supply for this pedicle?

A) Ascending branch from the fifth intercostal space
B) Ascending branch from the sixth intercostal space
C) Descending branch from the first intercostal space
D) Descending branch from the second intercostal space
E) Descending branch from the fourth intercostal space

D) Descending branch from the second intercostal space

Almost 60% of the blood flow to the breast is from the internal mammary artery. The second and third anterior perforating branches are most dominant. In a superomedial pedicle both the second and third descending branches are captured in the pedicle. In a pure medial pedicle, it is usually the third. The other branches do not constitute any significant contribution to the pedicle blood supply in a superomedial or medial reduction.

98

A 16-year-old girl is referred to the office because of an 8-month history of sudden and rapid enlargement of the right breast. She reports no other symptoms. Physical examination shows a large, palpable mass on the lower half of the right breast. Marked nipple-areola complex stretching, prominent dilated veins, and skin ulceration inferolateral to the mass are noted. Mammography and ultrasonography show a dense, circumscribed, homogenous 8-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 tumo

C) Giant fibroadenoma

This patient has a fibroadenoma, the most common breast neoplasm in adolescent females. Giant fibroadenomas are typically solitary, firm, nontender, and symptoms include a rapid asymmetric breast enlargement with prominent overlying veins and occasional pressure-induced skin ulceration. These lesions are larger than 5 cm and occur at or soon after the onset of puberty. These lesions are typically treated with enucleation using reduction mammaplasty 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 of 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.

Carcinoma would be unlikely in this age demographic. The differential diagnosis would additionally include cystic enlargement, breast hypertrophy, or phyllodes tumor.

Juvenile breast hypertrophy may occur as unilateral or bilateral breast enlargement. The enlargement is diffuse without evidence of a discrete mass or nodularity. Juvenile breast hypertrophy typically occurs 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 mammaplasty.

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.

99

A 37-year-old woman comes for evaluation of symptomatic macromastia after failure of conservative treatment. Height is 5 ft 4 in (163 cm) and weight is 245 lb (111 kg). BMI is 42 kg/m2. Physical examination shows Grade II ptosis and symmetrical macromastia. The estimated weight of tissue resection is 1200 g per side. An inferior pedicle reduction mammaplasty is planned. Which of the following places this patient at greatest risk for postoperative hematoma?

A) Hypotensive general anesthesia
B) Obesity
C) Omitting closed suction drains
D) The patient's age
E) Weight of the resected specimen

A) Hypotensive general anesthesia

The risks associated with reduction mammaplasty include local complications such as healing problems, nipple necrosis, loss of nipple sensitivity, infection, hematoma, hypertrophic scarring, fat necrosis, and asymmetry; systemic effects include deep venous thrombosis, pulmonary embolism, atelectasis, and a number of other surgical and anesthesia-related complications. The quantified risk of complications resulting from reduction mammaplasty increases with the weight of the resected specimen. These include wound-healing problems and nipple sensitivity. Some authors have recommended that normotensive anesthesia be administered throughout the procedure. While local and systemic risks are associated with elevated BMI, the degree of obesity does not demonstrate a correlation between risks and elevated body weight. The rate of hypertrophic scarring was shown to decrease with larger resections, possibly because of relief of skin tension or the presence of attenuated dermal thickness. Intraoperative hypotension, utilized to diminish blood loss during surgery, results in a higher rate of subsequent hematoma. Randomized studies documenting the risk of hematoma have shown no difference between patients with and without the use of closed suction drains.

100

A 15-year-old girl is brought to the office because her breasts have enlarged rapidly. She says she has severe back pain and posture problems. Her parents report that her brassiere size increased from 34B to 34E at age 13 years. There has been no increase in size for the past 12 months. Height is 5 ft 5 in (165 cm) and weight is 140 lb (63 kg). Which of the following is the most appropriate management?
A) Antiestrogen hormone therapy
B) Diet and exercise program to lose 15 lb (6.8 kg)
C) Reduction mammaplasty
D) Six-month testosterone injection protocol
E) Observation until the patient is age 18 years

C) Reduction mammaplasty

The accurate diagnosis of benign pediatric breast tumors is essential for proper treatment. When bilateral enlargement that is grossly out of proportion occurs at menarche, it is termed juvenile hypertrophy. After the enlargement has stabilized for approximately 1 year, the treatment is surgical. There is only anecdotal evidence for using antiestrogen hormone therapy (Tamoxifen). Proper diet and exercise would be expected to reduce the size slightly, but the usual resection in these cases is 1800 g or more.

The use of testosterone injection is not indicated for juvenile hypertrophy.

Observation, while indicated at first to allow the process to be fully manifested, would be appropriate after the size had stabilized for about a year. Then it would be appropriate for the surgeon to reduce the size if necessary. The differential diagnosis for pediatric breast enlargement includes fibroadenomas, phyllodes tumor, and cancer.

101

An 8-year-old girl is brought to the office by her mother because her daughter?s breasts have begun to develop. The mother says that her daughter has no history of serious illness. Height is 4 ft 2 in (127 cm, in 50th percentile) and weight is 55 lb (25 kg, in 50th percentile). Physical examination shows that her current cup size is a B. No pubic hair or vaginal mucosal thickening is noted. Which of the following is the most likely diagnosis?
A) Benign premature thelarche
B) Cushing syndrome
C) Gynecomastia
D) McCune-Albright syndrome
E) Precocious puberty

A) Benign premature thelarche

Knowledge of normal puberty and abnormal conditions of puberty is critical for any plastic surgeon evaluating the pediatric breast.

Tanner staging requires evaluation of pubic hair (males and females), genitals (males), and breasts (females). Because the patient described lacks pubic hair (Tanner I) and vaginal mucosal thickening, she has not started puberty in other areas. This excludes precocious puberty. If breasts develop before puberty has begun in other areas, it is considered benign premature thelarche and requires no intervention.

Gynecomastia is a hyperplastic condition of breast tissue. The patient described does not have hyperplastic breasts. In one series, hyperplastic breast abnormalities such as gynecomastia were the most common indication for operative intervention, with an average age of operation in the late teens.

McCune-Albright syndrome, also known as polyostotic fibrous dysplasia, is a condition characterized by premature puberty. Patients often begin menstruation before breast development. Patients also develop bony abnormalities, gigantism, and café-au-lait spots.