Breast

Question 1

Explain the Regnault classification

Answer 1

Grade 1: NAC below IMF but above lower pole of breast
Grade 2: Nipple below IMF but small amount of lower pole tissue below nipple
Grade 3: Nipple below IMF and no lower pole breast tissue below nipple

Question 2

Describe some indications for breast reduction surgery

Answer 2

Back pain
Neck pain
Shoulder grooving
Chronic headaches
Numbness in upper extremities
Intertriginous rashes or infections
Cervical or thoracic degenerative joint disease

Question 3

Define gynaecomastia

Answer 3

Benign, excessive enlargement of parenchymal breast tissue in the male breast

Question 4

Define pseudogynaecomastia

Answer 4

Diffuse fatty enlargement of the male breast related to obesity which demonstrates a predominance of adipose rather than fibrous tissue

Question 5

Name some risk factors for male breast cancer

Answer 5

Previous FH
Klinefelter’s syndrome
Cryptoorchidism
Orchitis
Radiation exposure
Exogenous oestrogens

Question 6

Explain the pathogenesis of gynaecomastia

Answer 6

Relative or absolute increase of circulating estrogens
Decreased circulating androgens
Enhanced sensitivity of breast tissue to estrogens

Question 7

How can you classify gynaecomastia

Answer 7

Idiopathic (most common)
Neonatal, pubertal or elderly
Pathological
Pharmacological

Question 8

Name some drugs that can cause gynaecomastia

Answer 8

Estrogens
HGH
Cimetidine
Methotrexate
Diazepam
Alcohol
Metronidazole
Digoxin
Spironolactone
Phenytoin

Question 9

How would you examine a patient with gynaecomastia?

Answer 9

Breasts: symmetry, nipple abnormalities, fat predominance, skin excess, ptosis; glandular tissue is characterised by mobile, rubbery subareolar breast tissue

Masses, lymph nodes
Secondary sexual characteristics; e.g. body hair distribution
Signs of systemic disease; e.g. ALD

Question 10

How would you manage gynaecomastia?

Answer 10

Conservative: treat underlying cause
Medical: tamoxifen or aromatase inhibitors
Radiation: no indication in idiopathic

Surgical: liposuction

Basic tenets of this are superwet infiltration, stab incisions along lateral IMF, use a radial cannula pattern across the chest and avoid adherent zone in the upper lateral pectoral region

Resection: open resection with direct excision of redundant skin or NAC repositioning in some cases