breast

Question 1

blood supply to the breast

Answer 1

IMA and thoracic artery perforators
lateral thoracic artery
intercostal arteries
thoracoarcomial artery
thoracodorsal artery

nerve supply of anterolateral branch of 4th intercostal nerve
the lateral branch runs through pec major and pierces the fascia below the NAC and enters the breast tissue from posterior surface

Question 2

preop w/u question

Answer 2

Breast related symptoms: nipple discharge, breast mass, galactorrhea, pain

family hx of breast ca

pregnancy, if desired and past

nicotine product use, BMI

Mammogram - would get on anyone older than 40, mammogram screening every 2-3 years after 45 and every year at 50. Get if family hx of cancer, palpable mass,

Question 3

giantomastia

Answer 3

removal of more than 1500 per side

Question 4

Juvenile Breast Hypertrophy

Answer 4

rapid onset of excessive glandular growth 11-14yo
Can do breast reduction, 50% have another in the future
Would want a stable size for 12mo
Counsel on potential breast feeding issues

Question 5

When should you do a reduction mammaplastu

Answer 5

failed tx of conservative management (PT, exercise, non-opioid pain meds), intertrigo, shoulder grooving

Question 6

preoperative counseling

Answer 6

-10-25% have a permanent reduction in nipple sensation, most return 3-12mo

cancer detection 0.5-1%

Question 7

breast implant

Answer 7

SILICONE - approved for 22 and older unless there is reconstruction
-less likely to have rippling
-more natural feel

Saline - approved for 18 and older
-higher rupture rates at 10 years, adjustable implant option, more prone to rippling

have patient complete the ASPS and company specific FDA form

Question 8

dual plane and types

Answer 8

1 - complete dissection of the pectorals with no dissection in the parenchyma-muscle interface

2 - complete dissection of pectoralis with elevation of glandular/muscle interface up to inferior boarder of NAC

3. up to superior boarder of NAC

Question 9

capsular contracture

Answer 9

1 - normal
2- normal appearance, but palpable on physical exam
3- visible contracture
3. pain

risks of capsular contracture is 10-17% at 10 years
20-25% at 10 years for revision augmentation

cause is unknown - suspected from increased inflammation, bleeding at surgery, serum, infection, biofilm, reoperation

Question 10

How would you minimize capsular contracture

Answer 10

meticulous hemostasis
pocket irrigation
minimize skin contact
nipple shields

MEDS: Leukotriene inhibitors like singulair (its off label use, check LFTs due to risk of hepatotoxicity, and monitor for mood related changes

Question 11

how would you treat capsular contractures

Answer 11

massage, leukotriene inhibitors (off label use, check LFT, behavior changes)

surgery - capsulectomy, replace implant (don’t reuse as there is likely biofilm on it), consider pocket change, post op LTI, massage

Question 12

BIA ALCL

Answer 12

textured implants
1/1000-1/30000
presents wit persistent swelling, mass, pain, fluid at 8-10 years
send fluid for CD30 +, ALK - (primarily a T cell clonality)

treat with a complete capsulectomy, chemotherapy and or radiation
5% mortality vs 75% with primary breast ALCL which is ALK +

associated with both saline and silicone

Question 13

BIA SCC

Answer 13

epithelial based rumor, aggressive
pathology showed sheets of squamous cells in nests and bundles
can go to lymph nodes, local tissue, mets to bone and muscle
presents 23 years since presentation
smooth and textured, saline and silicone

CK5/6+, p63+ flow cytometry positive for squamous cells and keratin

Question 14

mastopexy

Answer 14

pseudootosis - breast tissue below IMF, but NAC above
1 - at IMF
2 - NAC below but above dependent portion of breast
3 - NAC below IMF and most dependent portion of breast

Question 15

sub glandular vs subpec blood supple

Answer 15

thoracoacromial

Question 16

tuberous breast

Answer 16

pseduoherniation of breast content into areola with hypertrophy of NAC
constricted inferior pole
elevated IMF
vertical contraction with reduced height
hypoplasia of the breast, commonly with sever asymmetry

how to approach? periareolar approach, radial scoring, release of IMF, augment, possible NAC reduction and periareolar reduction

if the tuberous breast deformity is severe do expander

Question 17

Poland Syndrome

Answer 17

hypomastia, absent sternal head of pec
look for ipsilateral brachysyndactyly (shortening and syndactyly)
can see anterior thoracic hypoplasia

Question 18

How to reconstruct polands syndrome

Answer 18

need to create a new axillary fold, need volume for breast mound and possible NAC reconstruction

can use latissimus for axillary fold, keep humeral attachment
implant vs fat grafting

address nipple accordingly

Question 19

Gynecomastia

Answer 19

idiopathic
can be from increased circulating estrogens, cirrhosis, adrenal tumor, hypogonadism, marijuanam CCB, spironolactone, anabolic steroids, HIV meds, TCA, diazepam

increased risk of CA in Klinfelters syndrome patients

Think about mammogram, testicular US, thyroid studies, weight loss, stop drugs if any, if present for at least a year do something

Question 20

which breast cancer should you not do an immediate breast recon on

Answer 20

inflammatory breast ca

Question 21

What should you ask the patient regarding breast recon?

Answer 21

think size, pre mastectomy weight, asymmetry, need for a mastopexy? BMI, one operation vs many, maintenance and desire for alloplastic vs autogenous

Question 22

BCT

Answer 22

think reconstruction with ATR, oncoplastic reduction, delayed fat grafting and asymmetry procedures after XRT

Question 23

Oncoplastic mastopexy

Answer 23

which pedicle, go to basics…

Question 24

NSM

Answer 24

indications???
more than 2cm from nipple, <5cm in size, not multi focal, no angiolymphatic involvement

NEED TO PERFORM BIOPSY UNDER THE NIPPLE IF DOING THE NSM,,,,NOT INDICATED IF IT IS PROPHYLACTIC

Question 25

is there a benefit to immediate reocnstruction

Answer 25

psychological benefit has been shown

Question 26

when do breasts get radiatoin

Answer 26

definitive yes:
T3 and node positive, T4, more than 4nodes
stong trend and consideration to treating node positive with radiation vs Axillary dissection

Question 27

TE basics

Answer 27

Goldilocks vs? burrito?? what will you say??
expanding starts at 2 weeks
done over 6 weeks

can do implant exchange at 3mo if no adjacent treatment
herceptin not shown to be detrimental to wound healing
otherwise don’t want to touch patient for 4 weeks after chemo for 2nd stage

post-mastectomy radiation will change the timeline…how? wait 6mo

two rules are no sx for 6mo radiation and 4weeks for chemo

Question 28

implant to discuss with patient

Answer 28

implant failure is 1% per year
less surgeries
with no radiation contracture rate may be 20%
with surgery it is as high as 50-70%

Question 29

complications with implants

Answer 29

can try PO abx for cellulitis for 3days, after consider IV
usual stuff with implant salvage, replace with new implant/expander

Question 30

complications of fat grafting to breast

Answer 30

oil cyst
resorption
fat necrosis
micro calcifications
infection
nodules
contour abnormalities

Question 31

disadvantages of a pedicles TRAM

Answer 31

partial flap losss
higher rate of flap necrosis, likely from congestion
loss of core muscle

to minimize can cot the SIEA/SIEV and DIEA/DIEV 2 weeks prior

Question 32

THERE IS NO STANDARD FOR FLAP SURVELIANCE

Answer 32

CAN CONSIDER MRI/US at 5 years and 2-3 years after that