Breast Flashcards
An obese, 43-year-old woman has onset of lymphedema of her right arm 4 months after
undergoing modified radical mastectomy with adjuvant radiation therapy. In addition to
decongestive therapy, she is fitted for a daytime compression garment. Which of the
following factors is most critical to the effectiveness of this modality?
A ) Compression should be avoided when cellulitis is present
B ) Compression should be constant throughout the limb
C ) Compression should be a minimum of 20 mmHg
D ) Garments must be worn continuously
E ) Garments should be custom fit to the patient
The correct response is Option C.
Compression garments are a necessary adjunct to lymphedema therapy. They come in a
variety of pressures. In the US, these are designated by class: 1) 20-30 mm Hg; class II) 30
40 mmHg, class III) 40-50 mmHg; and class IV) >50 mmHg. Generally, more severe cases
of lymphedema require higher-class sleeves. Compression garments may be removed while
sleeping as long as the extremity is elevated. In addition, compression should be graduated
from distal to proximal. Garments can be custom fit or purchased over the counter in
standard sizes; there is no evidence that custom garments are better so long as a good fit is
achieved. An open wound or infection is not a contraindication to wearing a compression
garment.
2019
A 52-year-old woman undergoes autologous breast reconstruction with unilateral deep
inferior epigastric perforator (DIEP) flaps. According to the Hartrampf model of
perfusion zones, if the lateral row perforator vessels are used, in which chronological
order will the flap zones be perfused?
A ) I – II – III – IV
B ) I – III – II – IV
C ) II – I – III – IV
D ) II – I – IV – III
E ) IV – III – II – I
The correct response is Option B.
In medial perforator-based flaps, the zones are perfused in the order I – II – III – IV (A) as
shown in the image. In lateral perforator-based flaps, however, the zones are perfused in the
order I – III – II – IV (B).
A 54-year-old woman with a history of left mastectomy for breast cancer presents for
right reduction mammaplasty for symmetry. In this patient, the incidence of occult
breast cancer discovered incidentally in tissue specimens at the time of reduction
mammaplasty is approximately which of the following?
A ) 0.4 %
B ) 1 %
C ) 5 %
D ) 15 %
E ) 23 %
The correct response is Option C.
There have been multiple studies on the incidence of breast cancer discovered in reduction mammaplasty specimens. The incidence of occult cancer detected in reduction
mammaplasty specimens is typically very low (0.06 to 5.45%) but varies depending on the
patient’s age and history of breast cancer. One specific study compared women undergoing
reduction mammaplasty for symptomatic macromastia with women undergoing reduction
mammaplasty for symmetry after mastectomy with or without reconstruction. Incidentally
discovering occult breast cancer was much higher in women undergoing symmetry
procedures (5.5 vs. 0.4%) versus those undergoing reduction mammaplasty for symptomatic macromastia. The important distinction in this clinical vignette is that the woman has had a mastectomy for breast cancer, and highlights several important points including:
1) The importance of a thorough history before reduction mammaplasty
2) Preoperative clinical examination
3) Screening mammography prior to the reduction mammaplasty
4) Pathologic examination of reduction mammaplasty specimens
Based on multiple studies, the other percentages listed are either too high or too low.
The treatment of occult cancers discovered during reduction mammaplasty depends on
several factors including family history and evaluation of surgical margins.
2019
A 28-year-old woman undergoes cosmetic augmentation mammaplasty with silicone implants. Which of the following organisms is most likely to contribute to a biofilm associated with this patient’s procedure?
A) Candida albicans
B) Citrobacter koseri
C) Enterococcus faecalis
D) Escherichia coli
E) Staphylococcus epidermidis
E
A biofilm is a microbial community that produces an extracellular polymeric substance matrix, which allows the microorganisms to adhere together and to surrounding surfaces.
Biofilms are prevalent, pervasive, and may contribute to up to 80% of all infections. Biofilms are a significant risk when associated with indwelling medical prostheses. A strong clinical correlation is found in human clinical studies between the presence of biofilm and subclinical infection leading to capsular contracture of breast implants. This is related to the chronic inflammatory state of a biofilm, which may upregulate proinflammatory cytokines, which can activate myofibroblasts and contribute to capsular contracture.
Multiple interventions to decrease implant contamination at the time of surgery have been studied, including occlusive nipple shields, implant funnels, antimicrobial pocket irrigation fluids, intravenous antibiotics, and surgical techniques including choice of incision and implant pocket.
The detection of a subclinical infection in the form of biofilms has recently been confirmed in multiple studies. Staphylococcus epidermidis is part of the microflora of the skin and endogenous breast flora, and it has been implicated in the majority of detected breast implant biofilms. These bacteria could gain access to implants during surgery, particularly when a peri-nipple-areola or trans-nipple-areola approach is performed. Enterococcus faecalis, Escherichia coli, Candida albicans, and Citrobacter koseri all may contribute to breast implant biofilm and infection, but multiple studies have shown that one of the most common organisms associated with breast implant biofilm is coagulative-negative staphylococci.
2024
A 27-year-old woman comes for follow-up evaluation after undergoing bilateral transaxillary subglandular augmentation mammaplasty 2 months ago. On the night of the surgery, she developed a left breast hematoma, which required emergency surgical evacuation through the original incision. Today, the patient reports numbness of the upper outer quadrant of skin and the nipple-areola complex, which has not improved since the emergent operation. Damage to which of the following intercostal nerves is the most likely cause of the numbness in this patient?
A) Anterior cutaneous branch of fifth
B) Anterior cutaneous branch of fourth
C) Anterior cutaneous branch of second
D) Lateral cutaneous branch of first
E) Lateral cutaneous branch of third
The correct response is Option E.
According to multiple anatomical studies, multiple lateral and anterior cutaneous branches of the intercostal nerves innervate the skin and nipple/nipple-areola complex of the breast.
The lateral cutaneous branch of the third intercostal nerve innervates the upper outer quadrant of breast skin and nipple-areola complex. Anterior cutaneous branches of the second through fifth intercostal nerves are involved with medial upper and lower quadrants of the skin and nipple-areola complex.
The nipple-areola complex is consistently supplied by the anterior and lateral cutaneous branches of the fourth intercostal nerve, with additional innervation by cutaneous branches of the third and fifth intercostal nerves. The lateral cutaneous branch of the fifth intercostal nerve provides the sensation of the lower inner quadrant of the breast.
None of the studies showed the involvement of anterior and lateral cutaneous branches of the first and seventh intercostal nerves.
2024
A 34-year-old woman who recently underwent bilateral cosmetic augmentation mammaplasty with silicone implants is evaluated for multiple systemic symptoms. The patient reports joint and muscle pain, chronic fatigue, memory and concentration problems, breathing problems, sleep disturbance, rashes and skin problems, dry mouth and eyes, anxiety, depression, headaches, and hair loss. Which of the following laboratory studies is most appropriate to diagnose breast implant illness?
A) Antinuclear antibody
B) Blood culture
C) C-reactive protein
D) Erythrocyte sedimentation rate
E) No tests are diagnostic for this condition
The correct response is Option E.
Currently, there are no diagnostic tests or diagnostic criteria specifically for breast implant illness. Breast implant illness is a clinical diagnosis.
2024
A 38-year-old woman who underwent saline-filled prosthetic augmentation mammaplasty reports symptoms associated with breast implant illness. She would like to consider surgical management. Which of the following is the most evidence-based treatment modality to address the symptoms in this patient?
A) En bloc capsulectomy
B) Explantation
C) Implant deflation
D) Implant downsizing
E) Mastopexy
The correct response is Option B.
The concept of breast implant illness (for example, its definition, presentation, and treatment) remains somewhat unresolved in the literature. However, most agreement related to treatment centers on explantation. Capsule management is more controversial. Recent publications have not shown additional symptom resolution when capsulectomy is added to explantation. Implant exchange and size adjustment, deflation, and mastopexy have not been shown to improve symptoms of breast implant illness.
2024
A 21-year-old woman seeks augmentation mammaplasty for mammary hypoplasia. Use of a funnel for prosthetic manipulation is most likely to decrease the risk for which of the following complications?
A) Capsular contracture
B) Double-bubble deformity
C) Implant leak
D) Nipple-areola hypoesthesia
E) Overdissection of the lateral pocket
The correct response is Option A.
Funnels are employed to decrease the risk for bacterial contamination of implants. Many studies have linked bacterial contamination, inflammation, and risk for capsular contracture. The use of a funnel does not usually impact pocket dissection, either laterally or inferiorly, as in a double-bubble deformity. A funnel does not impact the leak rates of implants over time and does not usually impact soft-tissue dissection that might impact nipple-areola complex hypoesthesia.
2024
A 23-year-old woman undergoes augmentation mammaplasty with silicone implants. Which of the following best describes the U.S. Food and Drug Administration recommendation for how often this patient should undergo postoperative screening for asymptomatic rupture?
A) Initial screening at 1 year, then every year thereafter
B) Initial screening at 3 years, then every 2 years thereafter
C) Initial screening at 3 years, then every 5 years thereafter
D) Initial screening at 5 years, then every 2 years thereafter
E) Initial screening at 5 years, then every 5 years thereafter
The correct response is Option D.
The U.S. Food and Drug Administration (FDA) recently issued new requirements in the labeling of breast implants. Manufacturers are required to disclose all materials that are currently found in their implants, and boxed warnings must outline any potentially significant health risks that may be associated with having breast implants. In addition, a Patient Decision Checklist that identifies the risks/benefits and potential side effects must be given to and signed by each patient considering implants.
With respect to screening recommendations, the FDA now suggests implant rupture screening for asymptomatic patients via ultrasonography or MRI at 5 years after initial implantation, and then every 2 years thereafter. For symptomatic patients at any time and for those with equivocal results for rupture on ultrasonography, MRI is recommended.
2024
A 27-year-old woman presents with a swollen and painful right breast 2 weeks after undergoing bilateral augmentation mammaplasty using periareolar incisions. The patient is afebrile. Results of laboratory studies show white blood cell count is within reference ranges. Ultrasonography of the breast shows a 200-mL fluid collection. Ultrasonography-guided aspiration yields white fluid that tests positive on Sudan IV stain. Gram stain and cultures are negative. Which of the following is the most appropriate next step in management?
A) Administration of bromocriptine after checking serum prolactin concentration
B) Empiric administration of broad-spectrum oral antibiotics
C) Washout and removal of breast implant in the operating room
D) Washout and removal of the existing breast implant and placement of new implant in the operating room
The correct response is Option A.
The patient has a postoperative galactocele after undergoing augmentation mammaplasty. Galactorrhea and/or galactocele are uncommon but known complications after any breast surgery including augmentation mammaplasty.
Galactorrhea is usually bilateral and multiductal, and the discharge is milky (although it can be yellow, green, or brown). If the diagnosis of milk production is in doubt, Sudan IV staining for fat droplets in the nipple discharge can confirm the diagnosis. Gram stain and cultures are negative since its not an infection. Periareolar incisions are in the closest proximity to the lactiferous ducts compared with other incisions, meaning increased damage and subsequent implant contamination and infection if galactorrhea does occur. Management includes measuring serum prolactin concentrations and treatment with a dopamine agonist drug. This patient does not have infection or galactorrhea, so surgery with explantation and antibiotics are not warranted.
2024
A 72-year-old woman who underwent augmentation mammaplasty 20 years ago comes to the office because of a history of unilateral swelling of the right breast. Ultrasonography of the right breast shows a large seroma. Immunohistochemistry analysis of the seroma fluid is positive for CD30 and confirms breast implant-associated anaplastic large cell lymphoma. Workup shows localized disease. Which of the following is the most appropriate treatment for this patient?
A) Aspiration of seroma
B) Removal of both breast implants and bilateral total capsulectomy
C) Removal of the right breast implant and right-sided total capsulectomy
D) Removal of the right breast implant only
E) Observation
The correct response is Option B.
Treatment of localized breast implant-associated anaplastic large cell lymphoma is removal of both breast implants with bilateral total capsulectomy, since in approximately 4.6% of cases, lymphoma was found in the contralateral breast. Observation, aspiration only, and removal of the implant without capsulectomy are not appropriate treatments.
2024
A 24-year-old woman with pectus carinatum comes to the office to discuss augmentation mammaplasty. This patient is at greatest risk for which of the following postoperative outcomes?
A) Double-bubble deformity
B) Inadequate cleavage
C) Medial displacement of implant
D) Ptosis
E) Symmastia
The correct response is Option B.
Pectus carinatum (or keel chest or pigeon chest) is a congenital growth pattern of the sternum characterized by a prominent sternum that juts forward. It is the second most common chest deformation following pectus excavatum. Both are felt to be related to abnormal growth patterns in the costochondral junctions at the insertion of the ribs into the sternum and can be associated with connective tissue syndromes such as Marfan and Loeys-Dietz syndromes. Patients with severe deformities may have cardiorespiratory embarrassment and are treated by pediatric and thoracic surgeons to correct the sternal and rib positions to improve the thoracic cavity mechanics.
In plastic surgery, asymptomatic patients with mild deformities may present for augmentation mammaplasty. In a group of 400 women presenting for mammaplasty, Ors found 10% (N=40) had identifiable chest wall deformities, of which pectus carinatum accounted for five cases. This would extrapolate out to 1.25 of every 100 women presenting for augmentation.
When assessing the chest wall prior to considering augmentation mammaplasty, mild deformations should be pointed out to the patient prior to surgery to temper expectations. The surgeon should have strategies to avoid pitfalls associated with the deformation and techniques to improve the appearance.
With the prominent sternum in pectus carinatum, the breast tissue appears lateralized on the chest wall with a wide distance between the nipples and may be centered low on the pectoralis muscle. With this anatomy, symmastia is unlikely; more likely is inadequate cleavage. Inadequate cleavage can be addressed by using several strategies for pocket control and selecting the appropriate implant type. With the shape of the chest wall, lateral displacement of the implant is more likely than medial displacement. Double-bubble deformity and ptosis are related to management of the inframammary fold rather than the sternal shape.
2024
A 63-year-old man comes to the office for consultation regarding correction of large breasts. Detailed history and physical examination show no cause of his condition. The breasts are a size C cup with ptosis and excessive skin. The nipples are 5 cm in diameter. Mastectomy and free nipple grafts are planned. The desired new size and shape of each areola are closest to which of the following?
(A) 1 cm, round
(B) 2 cm, round
(C) 2 cm, oval
(D) 3 cm, oval
(E) 4 cm, round
The correct response is Option D.
Larger forms of gynecomastia with significant ptosis present a challenge to plastic surgeons with respect to the size, shape, and position of the nipple on the chest wall. In addition, the nipple-areola complex may need to be reconstructed due to loss from cancer or trauma.
Two recent studies investigated the anatomical parameters of the nipple-areola complex in men. These studies demonstrated the following characteristics. More than 90% of the male subjects had nipples that were oval in configuration. The average areolar diameter in one study was 2.8 cm. The average areolar diameter in the other study was 2.7 cm. Furthermore, in men, the position of the nipple on the chest wall is typically 20 cm from the sternal notch and 18 cm from the midclavicular line. The ideal nipple-to-nipple distance in men is 21 cm.
A 30-year-old woman comes to the office for evaluation of hypoplasia of the left breast and elevation of the nipple-areola complex. Physical examination shows no abnormalities of the right breast. The patient is diagnosed with Poland syndrome and is scheduled to undergo fat grafting and bilateral silicone breast implant placement to achieve symmetry. Which of the following best describes this patient’s future risk for developing breast cancer in the affected breast?
A) Greater than average due to fat grafting
B) Greater than average due to the presence of a silicone implant
C) Less than average due to hypoplasia of the breast
D) Less than average due to the presence of a congenital deformity
E) Similar to that of the general population
The correct response is Option E.
The association between some congenital disorders and the development of cancer is well recognized. Poland syndrome is frequently associated with Hodgkin disease, some types of leukemia or leiomyosarcoma, renal tumors, and lung tumors, but there are few reports on the association between Poland syndrome and breast cancer. The low incidence of Poland syndrome (1 in 30,000 live births) and the sex ratio (boys to girls = three to one) also makes statistical correlation between Poland syndrome and breast cancer difficult.
Despite the presence of less breast tissue with hypoplastic breast status, women with Poland syndrome are not at decreased risk for breast cancer either. In addition, researchers have shown that the hypoplasia of the breast does not make the discovery of the breast tumors easier. In this sense, it seems that the risk for breast cancer in Poland syndrome mimics that of the general population, and screening recommendations should follow accordingly. Mammography (along with ultrasonography and MRI, if indicated) should be given consideration before any decision is made for breast surgery or reconstruction in a patient with Poland syndrome.
No studies to date have shown a significant increase in the risk for breast cancer in women with a history of silicone implants or autologous fat grafting.
2024
A 19-year-old woman comes to the office for consultation regarding improvement of the appearance of her breasts. As an avid athlete, she declines latissimus flap reconstruction. A photograph is shown (absent pec major sternal head). Which of the following is the most appropriate next step in management?
A) Bilateral prophylactic skin-sparing mastectomy with a prepectoral custom-made implant
B) Deferring surgical management until age 21 years
C) Left vertical mastopexy
D) Placement of a total submuscular tissue expander in the right breast
E) Reconstruction with a right deep inferior epigastric artery perforator free flap
E
Poland syndrome is a congenital condition characterized by complete or partial pectoralis major muscle agenesis, breast and nipple aplasia or hypoplasia, and chest wall and rib malformation. A subset of patients have ipsilateral arm/hand maldevelopment, including brachydactyly and possibly syndactyly.
Reconstruction with a deep inferior epigastric artery perforator free (DIEP) flap is the best option from the choices. Because of the chest wall abnormalities, the anatomy of the internal mammary artery should be considered in selecting the recipient vessel. The internal mammary artery may be abnormally small or course retrosternal, and the thoracodorsal artery may need to be considered. The images show a staged postoperative picture following DIEP and before revision.
Although expansion of the skin may be a reasonable initial choice, placement of a total submuscular tissue expander would be difficult because of the aplasia of the sternocostal head of the pectoralis major muscle and possibly the entire muscle. While a custom-made silicone implant would be a good choice for this patient, bilateral prophylactic mastectomy is not indicated for Poland syndrome in the absence of breast cancer or genetic elevated risk for breast cancer, such as BRCA. Earlier surgical management is preferred to improve psychosocial development, and waiting until age 21 years has no advantage. Left-sided mastopexy alone would not address the volume discrepancy between the right and left breast causing asymmetry.
2024
A 14-year-old girl with Poland syndrome and significant breast asymmetry is brought to the office by her mother. The patient reports a negative impact to her social and mental well-being. On physical examination, the right breast is a DD cup size with otherwise normal appearance. The left side has a significantly smaller breast and absence of the pectoralis major muscle. Which of the following is the most appropriate next step in management?
A) Delayed reconstruction until patient is fully grown
B) Direct-to-implant reconstruction
C) Immediate autologous reconstruction
D) Staged reconstruction with tissue expander
D
The most appropriate next step in management is to plan a staged, implant-based reconstruction.
Poland syndrome is a congenital disorder involving the chest wall. The sequence of findings may vary but typically involves absence of the sternal portion of the pectoralis major muscle and lack of development of the soft tissue of the chest, including the breast in female patients. This may include partial or complete absence of the breast or musculature and structure of the arm. This patient has demonstrated that the abnormality is significantly affecting her quality of life and may further impact her social and emotional development. It is reasonable to consider starting reconstruction at this time. Given that her right breast is very large, at some point she may benefit from a reduction mammoplasty to help balance the dramatic difference of her chest size. Placing a tissue expander is ideal since it may be adjusted over time as she further develops on the right side. In addition to breast asymmetry, there may also be poor soft-tissue quality of the chest wall, necessitating additional procedures like a latissimus dorsi flap or fat grafting. Once the expander is successfully placed and expanded, the patient can decide when she would like to have definitive reconstruction and at what size. This should be done when she has stopped developing on the right side. Definitive reconstruction can be done with either autologous tissue or an implant depending on the patients body habitus and wishes.
Delaying her reconstruction until she has fully grown is likely to cause the patient to undergo a prolonged period of emotional suffering that may not be easily overcome. Performing definitive reconstruction at this time is not advisable since the patient has not fully developed.
2024
A 74-year-old woman is evaluated because of a right chest wound. History includes right modified radical mastectomy and postmastectomy radiation therapy completed 6 years ago. During the course of postmastectomy radiation therapy, the patient developed anterior chest wall skin breakdown, which was initially treated with local wound care and hyperbaric oxygen. Today, she presents with progression of the wound, fever, and worsening pulmonary function. Physical examination shows an exposed rib at the wound base and purulent drainage from the wound. A photograph and CT scan of the chest are shown. Which of the following is the most appropriate next step in management?
A) Continue local wound care and hyperbaric oxygen treatment
B) Operative debridement of soft tissues and closure with a local flap
C) Operative debridement of soft tissues, placement of bilaminate neodermis skin substitute, and staged split-thickness skin grafting
D) Thorough debridement including rib resections and coverage with a pedicled latissimus dorsi myocutaneous flap
E) Thorough debridement including rib resections, structural chest wall reconstruction with biologic mesh, and coverage with a pedicled latissimus dorsi myocutaneous flap
D
This patient has osteoradionecrosis of the right fifth and sixth ribs associated with a nonhealing wound and superimposed infection. In order to eradicate the infection and allow for wound healing, resection of the involved ribs will be necessary. Local wound care or debridement of soft tissues alone will leave devitalized bone in place and likely lead to eventual failure of any closure with a local flap. Furthermore, skin substitutes such as bilaminate neodermis are not suitable options in the setting of persistent infection and are less likely to be effective in the setting of severe radiation-induced soft-tissue injury. Therefore, management involving complete resection of the necrotic ribs is the only suitable option for eradicating infection and providing a wound bed capable of healing.
Although it is generally accepted that defects resulting from resection of fewer than four ribs do not necessitate rigid or semi-rigid chest wall reconstruction, this patient’s CT scan demonstrates elevation of the right hemidiaphragm with abdominal contents immediately beneath the involved ribs (fifth and sixth). As such, closure of this wound without some form of chest wall reconstruction will necessarily lead to hernia formation. Therefore, management involving reconstruction of the chest wall as well as soft-tissue coverage for wound closure is the most suitable answer. Phrenic nerve dysfunction can be caused by severe radiation injury, and although this is more commonly reported in the setting of stereotactic radiotherapy to the diaphragm and/or mediastinum, it can also occur in the setting of postmastectomy radiation therapy. This can lead to worsening pulmonary function and may benefit from operative plication of the diaphragm to restore higher lung volumes.
2024
A 42-year-old woman comes to the office to discuss breast reconstruction. She states that she is very active, does not want implants, and would like to avoid surgery on her stomach. Use of a profunda artery perforator flap is planned. The perforator to this flap has an intramuscular course through which of the following muscles?
A) Adductor magnus
B) Gracilis
C) Rectus femoris
D) Semitendinosus
E) Vastus medialis
The correct response is Option A.
The profunda artery perforator (PAP) flap has become a reliable alternative to abdominally based autologous breast reconstruction. The donor site is favorable, the harvest can be performed supine, and the vascular anatomy is consistent, resulting in adequate length and diameter of the pedicle. During harvest, the gracilis muscle is reflected anteriorly, and the adductor magnus fascia is entered. The perforator courses through the adductor magnus, requiring an intramuscular dissection.
The transverse upper gracilis (TUG) flap is supplied by the gracilis branch of the medial femoral circumflex artery. The TUG flap is a myocutaneous flap of the inner upper thigh. The gracilis muscle is included as part of this flap.
The other muscles are not part of the intramuscular dissection for the PAP flap.
2024
A 42-year-old woman is evaluated because of a 1-cm intraductal carcinoma of the upper outer quadrant of the breast. She is otherwise healthy. A nipple-sparing implant-based reconstruction is planned. Which of the following incisions is most likely to result in the most aesthetic outcome with acceptable nipple vascularity?
A) Horizontal radial
B) Inferior radial
C) Inferolateral inframammary fold
D) Periareolar
The correct response is Option C.
In this setting, the preferred incision would be the inferolateral inframammary fold incision since it has the best potential access to the reconstruction pocket, a lower mastectomy flap failure rate, and a lower risk for nipple complications compared with the other choices. The horizontal radial incision has similar vascular reliability in a patient with minimal ptosis but has a slightly higher mastectomy flap complication rate. The vertical radial incision is more optimally used for patients with more ptotic breasts, and periareolar incisions should be avoided in nipple-sparing cases since they have a high rate of nipple ischemia.
2024
A 62-year-old woman is evaluated 3 days after undergoing bilateral mastectomy with tissue expander placement. History includes hypertension, type 2 diabetes, and invasive ductal carcinoma. During the examination, the patient begins to experience the sudden onset of radiating chest pain, diaphoresis, and nausea. Which of the following is the most appropriate next step in management?
A) Deflate expanders
B) Measure serum troponin concentration
C) Obtain CT angiography of the chest
D) Obtain electrocardiogram
E) Reassure the patient
The correct response is Option D.
The patient in question is most likely suffering from an acute coronary syndrome. The next step in the management is to obtain an electrocardiogram (ECG) to identify ST elevation or other cardiac abnormalities.
Acute coronary syndrome encompasses a range of thrombotic coronary artery diseases. An ECG along with clinical history is necessary for diagnosis and effective intervention. The 2021 American Heart Association guidelines for evaluation and diagnosis of chest pain make several setting-specific recommendations. If possible, an ECG should be obtained and interpreted first. This prevents important and avoidable delays in emergency department readiness. If an ECG were unavailable, then transfer to the emergency department would be indicated.
The goals for managing patients with acute chest pain include: 1) identifying life-threatening causes, 2) determining clinical stability, and 3) assessing need for hospitalization.
CT angiography would be indicated to rule out a pulmonary embolism. There is no indication of hypoxia on clinical examination, and the first step in management is to rule out an acute cardiac abnormality.
Serum troponin evaluation is the most sensitive test for diagnosing acute myocardial injury, in conjunction with other clinical data. However, based on guidelines, delayed transfer to the hospital for diagnostic testing beyond ECG should be avoided.
This patient is experiencing a possible acute coronary event. Expander deflation and reassurance are not appropriate next steps.
2024
A 45-year-old pregnant woman at 8 weeks’ gestation is diagnosed with Stage I invasive ductal carcinoma following needle biopsy of a 3-cm breast mass that she discovered on self-examination. History includes pulmonary embolism several years ago associated with oral contraceptive use. She is otherwise healthy and wears a size 38DD brassiere. She is considering breast-conserving therapy (BCT) versus mastectomy. Which of the following is an absolute CONTRAINDICATION to BCT in this patient?
A) Age
B) Breast size
C) History of thromboembolism
D) Pregnancy
E) Tumor size
The correct response is Option D.
Breast-conserving therapy (BCT) is the removal of breast cancer with clear surgical margins. It is referred to as “lumpectomy,” “wide local excision,” and “partial mastectomy.” BCT is indicated for a biopsy-proved diagnosis of ductal carcinoma in situ or invasive breast cancer with resectable margins and an acceptable cosmetic result. In addition to surgical treatment, radiation plays a crucial role.
The decision to undergo BCT takes many factors into account. Absolute contraindications to BCT include:
Early pregnancy
Multicentric tumor
Diffuse microcalcifications
Inflammatory breast cancer
Persistently positive margins
Relative contraindications to BCT include:
Prior breast/chest wall radiation
Large breast size
Large tumor size relative to breast volume
In the patient described, only pregnancy would be considered an absolute contraindication to BCT due to an unacceptable delay in radiation treatment. Age and thromboembolism are neither indications nor contraindications for BCT. The tumor is relatively small (3 cm) in relation to her large breasts, so breast conservation would be possible if the patient were not pregnant.
2024
A 60-year-old woman with a history of hormone-positive breast cancer presents for consultation for autologous breast reconstruction with deep inferior epigastric artery perforator flaps in a delayed fashion. She is currently taking anastrazole. To address thromboembolic risk, this drug should be held for which of the following intervals at the time of the operation?
A) 0 weeks before and 0 weeks after surgery
B) 2 weeks before and 0 weeks after surgery
C) 2 weeks before and 2 weeks after surgery
D) 4 weeks before and 0 weeks after surgery
E) 4 weeks before and 2 weeks after surgery
A
Anastrazole is an aromatase inhibitor, a type of hormonal therapy that is given for treatment of postmenopausal women diagnosed with hormone-positive breast cancer. Aromatase inhibitors are a class of drug that do not need to be stopped (held) perioperatively for microvascular operations. Other types of hormonal agents, like tamoxifen, have a known risk for blood clotting and therefore have historically been felt to have an increased risk for microvascular thromboses and flap loss. The data on tamoxifen, a selective estrogen receptor modulator, are mixed, with some studies finding an increased risk for microvascular compromise, while others do not. The original publication by Kronowitz in 2012 found an increase in flap loss and decrease in flap salvage in patients who had been treated with tamoxifen within 28 days of microvascular surgery, and as a result recommended holding it for 28 days prior to operation. Other papers have since reported no increased events in shorter time period (ie, 2 weeks) or no increased events without holding it at all. While the data are inconclusive on whether to hold tamoxifen, and for how long, multiple studies have demonstrated no increased microvascular risks in allowing patients to continue their aromatase inhibitors.
2024
A 39-year-old woman comes to the office for a consultation regarding breast reconstruction following bilateral nipple-sparing mastectomy. Immediate direct-to-implant reconstruction in the prepectoral plane with acellular dermal matrix is planned. In comparison with subpectoral reconstruction, which of the following is a primary benefit of prepectoral reconstruction?
A) Decreased material cost
B) Lower rates of implant rippling
C) Lower rates of upper pole contour deformity
D) Medial placement of implants
D
Breast reconstruction with prepectoral implants has emerged as a safe alternative to subpectoral reconstruction, although each reconstructive technique has its own benefits and disadvantages. A benefit of prepectoral breast reconstruction is that the implant can be placed medially in all cases, whereas this may be difficult in patients with a wide sternalis muscle in subpectoral cases. Implant rippling, which relates to implant visibility, is higher with prepectoral implantation due to less soft-tissue coverage. Material cost, which includes either acellular dermal matrices or synthetic meshes, is generally higher with prepectoral reconstruction versus subpectoral. Animation deformity, or the implant moving with pectoralis muscle contraction, is higher with subpectoral reconstruction. Upper pole contour deformity is higher with prepectoral reconstruction, again owing to less soft-tissue coverage.
2024
A 57-year-old woman with newly diagnosed invasive lobular carcinoma of the right breast presents for evaluation and requests immediate breast reconstruction following bilateral mastectomy. History includes no comorbidities. She is allergic to sulfa drugs, and she does not smoke cigarettes. She desires staged implant-based breast reconstruction. Which of the following is the most appropriate antibiotic prophylactic regimen for this patient?
A) Perioperative (duration less than 24 hours) intravenous cefazolin
B) Perioperative (duration less than 24 hours) intravenous clindamycin
C) Perioperative (duration less than 24 hours) intravenous vancomycin
D) Perioperative intravenous cefazolin followed by oral cephalexin (5-day course)
E) Perioperative intravenous vancomycin followed by oral trimethoprim/sulfamethoxazole (5-day course)
A
Postoperative surgical site infection following implant-based breast reconstruction is a major complication that can result in reconstructive failure. Therefore, maintenance of a sterile surgical field, meticulous surgical technique, and perioperative antibiotic prophylaxis are of utmost importance in decreasing postoperative infection rates.
While extended-duration antibiotics were administered routinely in the past following implant-based breast reconstruction, more recent studies have demonstrated that this practice does not decrease the incidence of postoperative surgical site infection following implant-based breast reconstruction. Importantly, Level I evidence has demonstrated that the practice of extended-duration antibiotic prophylaxis is, in fact, associated with a higher rate of reconstructive failure. These data have resulted in current recommendations consisting of limiting antibiotic prophylaxis to the perioperative period only (less than 24 hours).
Of note, recent data have demonstrated the superiority of beta-lactam antibiotics (eg, cefazolin) over alternative antibiotics with a bacteriostatic mechanism of action (eg, vancomycin, clindamycin) regarding rates of postoperative infection and reconstructive failure following immediate implant-based breast reconstruction.
Bactrim would be contraindicated in this patient given her sulfa allergy.
2024
