Breast Augmentation, Mastopexy 01-22, 24

Question 1

A 16-year-old girl is referred to the clinic by her pediatrician for correction of breast asymmetry. The patient reports that her right breast has always been smaller. Physical examination shows mildly shortened right fingers and a Tanner III right breast. Examination shows that the left breast is Tanner IV and no masses. Which of the following is the Mathes and Nahai Classification of the muscle most likely involved in this congenital disorder?

A) Type I
B) Type II
C) Type III
D) Type IV
E) Type V

Answer 1

The correct response is Option E.

The pectoralis major has a dual blood supply from both a dominant primary pedicle (pectoral branches of the thoracoacromial artery) and secondary segmental perforators (internal mammary/thoracic perforators).

The absence of the pectoralis major muscle and associated hand deformity is pathognomonic for Poland syndrome. The etiology is unclear but suspected due to vascular interruption during embryogenesis. The diagnosis is often delayed until puberty when asymmetric breast development is noted. Brachydactyly, syndactyly, or ectrodactyly are common and can present with various severity.

Type I flaps have a single dominant blood supply (e.g., rectus femoris or gastrocnemius muscles). Type II flaps have a dominant and minor vascular pedicle (e.g., gracilis or soleus muscles). Type III flaps have 2 dominant pedicles (e.g., pectoralis minor, rectus abdominis and serratus muscles). Type IV flaps only have segmental blood supply (e.g., sartorius or tibialis anterior muscles).

Question 2

A 45-year-old woman presents for a discussion regarding breast augmentation. She is concerned about the high incidence of capsular contracture and asks for postoperative antibiotic therapy. Medical history includes no known drug allergies. Which of the following is the most appropriate postoperative antibiotic therapy in this patient?

A) Cephalexin; 500 mg, four times daily for 7 days
B) Ciprofloxacin; 500 mg, twice daily for 7 days
C) Clindamycin; 300 mg, every 6 hours for 7 days
D) Sulfamethoxazole and trimethoprim; one double-strength tablet, twice daily for 7 days
E) Postoperative antibiotics are not indicated

Answer 2

The correct response is Option E.

For the patient in the scenario, postoperative (empiric/prophylactic) antibiotics are not indicated. Though capsular contracture is the most common long-term implant complication of breast augmentation, routine postoperative antibiotics have not been shown to decrease this complication. Capsular contracture can result in discomfort, pain, malposition, asymmetry, and the need for revision and reoperation. Though still the subject of hypotheses, the leading theory is that capsular contracture stems from a subacute infection leading to biofilm formation. In one study, the most common isolate was Staphylococcus epidermidis, implying contamination of the implant with insertion. Given this, several algorithms have been proposed to reduce the chance of contamination, including betadine irrigation, antibiotic irrigation, and utilization of a “no-touch.” Postoperative antibiotic therapy has not been demonstrated to be effective in preventing capsular contracture. Thus, all of the answers involving antibiotic prophylaxis are incorrect.

Question 3

A 31-year-old woman, gravida 2, para 2, presents for augmentation mammaplasty. She wants improved overall fullness with limited scarring. She currently wears a size 34A brassiere. Physical examination shows pseudoptosis. Submuscular augmentation with which of the following techniques is most appropriate to meet this patient’s goals?

A) Pectoralis muscle not released along inframammary fold
B) Release of pectoralis muscle along inframammary fold and periareolar mastopexy
C) Release of pectoralis muscle along inframammary fold and submammary dissection to inferior areola
D) Release of pectoralis muscle along inframammary fold and vertical mastopexy
E) Release of pectoralis muscle along inframammary fold only

Answer 3

The correct response is Option C.

The patient would benefit most from a type II dual-plane augmentation mammaplasty. Her breast parenchyma is moderately mobile over the pectoralis muscle, and she has moderate stretch of the lower pole skin. The goal of dual-plane augmentation is to maximize muscle coverage while allowing optimal lower pole expansion. It also allows redistribution of the breast tissue overlying a submuscular implant.

Soft tissue coverage of the implant is an important consideration regarding pocket location. If pinch thickness of the upper breast is 2 cm or greater, an implant can be placed above the pectoralis muscle. If pinch thickness is less than 2 cm, then the implant should be placed at least partially under the pectoralis muscle. If pinch thickness is less than 0.5 cm along the inframammary fold, then the pectoralis muscle should not be released along the inframammary fold.

There are three types of dual-plane augmentation. Type I releases the pectoralis muscle along the inframammary fold. This is used for most routine augmentation mammaplasties, with all the breast parenchyma above the inframammary fold, tight attachments of the parenchyma-muscle interface, and areola-to-inframammary fold stretch of 4 to 6 cm.

Type II dual-plane augmentation releases the pectoralis muscle along the inframammary fold and dissection is performed superficial to the pectoralis muscle to the inferior border of the areola. This is used for augmentation mammaplasties with most of the breast parenchyma above theinframammary fold, looser attachments of the parenchyma-muscle interface, and areola-to-inframammary fold stretch of 5.5 to 6.5 cm.

Type III dual-plane augmentation releases the pectoralis muscle along the inframammary fold, and dissection is performed superficial to the pectoralis muscle to the superior border of the areola. This is used for augmentation mammaplasties in patients with glandular ptosis or true ptosis, when a third of the breast parenchyma is below the inframammary fold, there are very loose attachments of the parenchyma-muscle interface, and areola-to-inframammary fold stretch is 7 to 8 cm. Type III can also be used in breasts with constricted lower poles.

Mastopexy increases scarring, which this patient wanted to limit, and is often not needed with the appropriate dual-plane approach.

Question 4

During puberty, which of the following hormones is responsible for the development of the glandular buds of the breasts?

A) Estrogen
B) Follicle-stimulating hormone
C) Oxytocin
D) Progesterone
E) Prolactin

Answer 4

The correct response is Option D.

During puberty, estrogen controls the growth of the breast ducts. Progesterone controls the growth of the glandular buds. Follicle-stimulating hormone, luteinizing hormone, prolactin, and oxytocin are responsible for milk production.

Question 5

A healthy 34-year-old woman presents to the emergency department for evaluation of a small, open wound of the right breast after an augmentation mastopexy that was performed 4 weeks ago in the Dominican Republic. The wound has not improved with local wound care and empiric treatment with oral antibiotics. She reports no fevers, chills, or malaise. Physical examination shows a 1-cm opening along the vertical incision below the nipple-areola complex with scant serous drainage noted. Which of the following is the most appropriate next step in treatment to address this patient’s findings?

A) Change the local wound care and oral antibiotic regimen
B) Debride the wound and remove the implant in the operating room
C) Excise and close the wound at bedside
D) Order an ultrasound-guided percutaneous drain placement
E) Start a course of intravenous antibiotics

Answer 5

The correct response is Option B.

Given this patient’s history of travel to Latin America for surgery, the diagnosis of an atypical mycobacterial infection, such as Mycobacterium abscessus, should be strongly considered. As such, the most appropriate treatment should include operative washout and debridement with removal of the infected prosthesis. Tissue should be sent for acid-fast staining, mycobacterial culture, and pathology.

More conservative treatment of this wound with continued local wound care or attempt at bedside closure will likely delay definitive diagnosis and treatment and lead to treatment failure. Intravenous antibiotics alone are not sufficient to treat an open wound with underlying implant involvement due to an atypical mycobacterial infection. Fluid collection is not suspected so ultrasound-guided drain placement is unnecessary.

Question 6

A healthy 14-year-old girl presents to the office for evaluation of her breasts. Physical examination shows a superiorly positioned nipple-areola complex with absent breast tissue on the right side and otherwise normal breast development on the left. She wears a B-cup brassiere but uses a brassiere insert on the right. Her mother states that this asymmetry causes the patient significant emotional distress, and they would like to discuss surgical options. Which of the following mammaplasty techniques is most appropriate to address this patient’s right breast findings?

A) Deep inferior epigastric perforator flap
B) Latissimus dorsi myocutaneous flap
C) Saline implant augmentation
D) Structural fat grafting
E) Tissue expander placement

Answer 6

The correct response is Option E.

This young, healthy, adolescent girl has amastia of the right breast. Absence of breast tissue along with a superiorly malpositioned nipple-areola complex strongly indicates that tissue expansion may be required prior to formal reconstruction with either an implant or autologous tissue. Since the left breast tissue is still developing, a first-stage right breast tissue expander allows for expansion of the breast pocket, adjustment of breast size as the patient grows, and eventual implant or autologous tissue reconstruction tailored to her body habitus and desires once she reaches maturity.

Question 7

A 48-year-old woman interested in mastopexy presents with C-cup breasts, grade 3 ptosis, striae of the breast skin bilaterally, 5-mm upper pole pinch thickness, and 7-cm diameter areolae. Which of the following is the strongest CONTRAINDICATION to a circumareolar-only approach to mastopexy?

A) Breast skin striae
B) C-cup breast size
C) Grade 3 ptosis
D) 5-mm upper pole pinch
E) 7-cm diameter areolae

Answer 7

The correct response is Option C.

Circumareolar-only approaches to mastopexy are unlikely to be successful with severe ptosis (such as in this patient with grade 3 ptosis) and are usually recommended for patients with only mild-to-moderate ptosis. Moderate breast size (C cup) would not likely impact the success of this surgical approach. The striae are also unlikely to specifically impact a circumareolar approach but may indicate poor skin quality predisposed to recurrence of ptosis corrected with a variety of surgical techniques. The thin upper pole pinch (5 mm) would more likely impact implant-based decision-making. Wide areolae (7 cm) are suitable for circumareolar surgical techniques.

Question 8

A 22-year-old woman who is dissatisfied with the appearance of her breast seeks surgical correction. Examination shows a constricted base width, widened areola, and areola herniation. Which of the following is the most likely diagnosis?

A) Athelia
B) Hypomastia
C) Poland syndrome
D) Pubertal arrest
E) Tuberous breast

Answer 8

The correct response is Option E.

The examination findings are consistent with the diagnosis of tuberous breast. Athelia is defined as absence of the nipple. Hypomastia would include a component of small breast volume, not described in this scenario. Poland syndrome often presents with an underdeveloped chest wall, including potential absence of the pectoralis major muscle. Pubertal arrest might allow for a disproportionately widened areola and apparent herniation if the breast bud had not fully developed, but it would not likely be associated with a constricted breast base width, which demonstrates breast development past the early stages of sexual development (known as Tanner stages).

Question 9

A 52-year-old woman with a 15-year history of subglandular breast implants presents with concerns about obtaining her first mammogram. She states that she has avoided mammography because she is concerned about implant rupture from the procedure. Which of the following is the most appropriate next step?

A) Diagnostic mammography with Eklund views
B) Diagnostic mammography with Waters views
C) MRI with contrast
D) Screening mammography with Eklund views
E) Screening mammography with Waters views

Answer 9

The correct response is Option D.

The correct answer is screening mammography with Eklund views. Some women report that they are hesitant to undergo screening mammography because they are afraid of an implant rupture. A study of breast implant complications reported to the Food and Drug Administration (FDA) demonstrated that of 714 breast implant adverse events reported, 66 described rupture or problems directly associated with mammography. In addition to implant rupture, an oncologic concern is inadequate x-ray views for assessment of the breast tissue.

Eklund described a modified position for mammography in which the breast tissue is displaced in front of the implant. This allows for adequate assessment of the breast tissue. Screening mammography is appropriate for routine mammography; diagnostic mammography is used to further characterize mammographic concerns or in the case of known pathology.

While MRI is used to detect silicone implant rupture and as an adjunct in oncological screening, it is not currently recommended as a routine primary screening tool.

It should be noted that the presence of breast implants should not be used to justify deferral of recommended oncologic screening, and the true incidence of breast implant rupture caused by mammography is difficult to assess given the different generations of implants and the possible presence of capsular contracture.

Waters views are used to assess the maxillary sinuses.

Question 10

An 18-year-old fair-skinned woman presents with a pigmented lesion on her abdominal wall. She reports no symptoms. On examination, a 2-mm lesion appears as a brown-colored protuberance along the milk lines. Which of the following is the embryologic basis for this condition?

A) Anhidrotic ectodermal dysplasia
B) Arrested mammary ridge development
C) Failure of regression of mammary ridges
D) Hypertrophy of glandular tissue
E) Hypoplasia of ectodermal ductal system

Answer 10

The correct response is Option C.

Supernumerary nipples (polythelia) occur in 2 to 5% of humans in a position from the groin to the axilla. During the fourth week of embryo development, normally a pair of epidermal thickenings called the mammary ridges develop along the milk lines on either side of the body. These supernumerary nipples can appear similar to pigmented macules or fully developed nipple-areola complexes. These are rarely functioning but can occasionally be a cosmetic issue. Hypertrophy of glandular tissue is macromastia. Arrested mammary ridge development is found during polymastia. Anhidrotic ectodermal dysplasia can be seen in amastia. There is no hypoplasia of ectodermal ductal system in breast development.

Question 11

A 15-year-old girl presents for evaluation of hypoplasia of the right breast. Examination shows an underdeveloped left breast, superiorly displaced nipple-areolar complex, and sunken-appearing chest wall. The pectoralis major muscle and sternum are normal. Which of the following is the most likely diagnosis?

A) Amastia
B) Amazia
C) Anterior thoracic hypoplasia
D) Athelia
E) Poland syndrome

Answer 11

The correct response is Option C.

Anterior thoracic hypoplasia is characterized by hypoplasia of the breast in the context of normal sternum and normal pectoralis major muscle. It is on the differential diagnosis of congenital breast deformities, and is distinguished from Poland syndrome by the normal pectoralis major muscle. Pectus excavatum is another condition of the chest wall; it is characterized by abnormal development of the sternum and ribs, and does not affect breast growth, although it can cause medial displacement of the breasts. Pectus excavatum is more common in males than females. Treatment of the breast in Poland syndrome and anterior thoracic hypoplasia depends on the degree of deformity and the goals of the patient; both implant-based reconstruction and fat grafting have been used.

Amazia is an absence of the mammary gland with a present nipple areolar complex, and amastia is complete absence of the mammary gland and nipple areolar complex.

Athelia is an absence of the nipple.

Question 12

A 34-year-old woman desires improvement of the appearance of her breasts and abdomen. Physical examination shows a supernumerary nipple with a small bud of breast tissue just under the fold of the left breast. The embryologic origin and development of this accessory structure occur as a result of which of the following?

A) Incomplete differentiation of the ectodermal ridge
B) Incomplete differentiation of the mesodermal ridge
C) Incomplete involution of the ectodermal ridge
D) Incomplete involution of the mesodermal ridge

Answer 12

The correct response is Option C.

In utero, the breasts develop from paired mammary ridges of thickened ectoderm which extend from the axillae to the inguinal regions. The ectoderm will give rise to the nipple and ductal elements, while the mesoderm will eventually give rise to the connective tissue and vascular structures of the breast. Polythelia, or supernumerary nipples, occur as a result of incomplete involution of one of the many epithelial buds along the mammary ridge.

References

Question 13

A 20-year-old woman presents with concerns about the appearance of her breasts. Examination shows unilateral herniation of the nipple-areola complex and a constricted lower pole. Which of the following maneuvers is most likely to address this patient’s concerns?

A) Elevation of the inframammary fold
B) Radial release of parenchymal bands
C) Skin grafting of nipple-areola complex
D) Vertical mastopexy
E) Wise pattern reduction mammaplasty

Answer 13

The correct response is Option B.

The patient description is consistent with tuberous breast deformity. Surgical intervention usually includes reduction of the periareolar herniation with periareolar incisions and radial release of parenchymal bands. Reduction would not address the issues associated with a tuberous breast. Vertical mastopexy alone through standard approaches would potentially further constrict the lower pole. Skin grafting of the nipple-areola complex would not address the tissue herniation. Elevation of the inframammary fold would not address the tuberous deformity and might exacerbate it.

Question 14

An otherwise healthy, 24-year-old woman presents for breast augmentation consultation. Physical examination shows polythelia. On the basis of this finding, which system is most likely to have associated abnormalities?

A) Gastrointestinal
B) Hematological
C) Pulmonary
D) Renal
E) Vertebral

Answer 14

The correct response is Option D.

The presence of a supernumerary nipple occurs in 2-6% of females. Polythelia is the presence of two or more supernumerary nipples. A correlation exists between renal disease and polythelia. It is associated with 19% of patients with renal adenocarcinoma and 16.5% of patients with end-stage renal disease. Regular physical examination and urinalysis should be performed in patients with polythelia and any noted abnormality should alert the physician to the need for a renal ultrasound.

References

Question 15

A 37-year-old woman with macrotextured saline implants placed 10 years ago was recently diagnosed with a peri-implant fluid collection. Ultrasound-guided aspiration of the fluid is performed and sent for Wright-Giemsa–stained smears, and cell block immunohistochemistry/flow cytometry testing. Images are shown. Which of the following results would confirm a diagnosis of breast-implant–associated anaplastic large cell lymphoma?

A) CD30 negative, ALK negative
B) CD30 negative, ALK positive
C) CD30 positive, ALK negative
D) CD30 positive, ALK positive

Answer 15

The correct response is Option C.

This patient has breast implant–associated anaplastic large cell lymphoma (BIA-ALCL) which is a distinct form of CD30-positive T-cell, non-Hodgkin’s lymphoma that arises in association with a breast implant after either reconstructive or cosmetic surgery. The disease is typically contained within the capsule and fluid immediately adjacent to the implant. Patients commonly present with delayed seroma, but can also present with pain, capsular contracture, and/or a palpable mass. BIA-ALCL risk is higher with textured devices and these concerns led to the 2019 FDA recall of Allergan Biocell devices. The recall includes older McGhan and Inamed implants and current Natrelle implants. When patients with suspicious history or symptoms are evaluated, pre-operative imaging (e.g., mammography, ultrasound, and/or MRI) is recommended with aspiration of identifiable fluid or biopsy of mass. Ultrasound is considered the diagnostic modality of choice. Diagnostic evaluation should indicate concern for BIA-ALCL to the pathologist to include cytological evaluation of seroma fluid or mass with Wright-Giemsa stained smears and cell block immunohistochemistry/flow cytometry testing for cluster of differentiation (CD30) and anaplastic lymphoma kinase (ALK) markers. Wright-Giemsa staining shows pleomorphic cells with horseshoe shaped nuclei, nuclear folding and abundant vacuolated cytoplasm. All known cases of BIA-ALCL are CD30-positive and -negative for ALK, distinct from systemic ALCL which is ALK-positive.

Question 16

A 19-year old woman presents with concerns about the appearance of her breasts. Examination shows asymmetrical breasts with grade III ptosis, small breast footprint of both breasts, and a large nipple-areola complex with herniation of breast tissue. Which of the following characteristics of the tuberous breast deformity contributes to the physical findings in this patient?

A) Hyperplasia of one or more quadrants
B) Hyperplasia of only medial quadrants of the breast
C) Hypoplastic areola
D) Low inframammary fold
E) Periareolar ring constriction

Answer 16

The correct response is Option E.

Tubular breasts are caused by connective tissue malformations and occur in puberty. Clinical characteristics include breast asymmetry, dense fibrous rings around the areola, hernia bulging of the areola due to hypoplastic fascial support, hypoplasia of one, two or more quadrants, narrowing of the breast base, and a high location of submammary folds.

References

Question 17

A 32-year-old woman comes to the office 2 years after undergoing bilateral breast augmentation with 350-cc smooth, round saline implants. The patient reports chronic fatigue and joint pain. Physical examination shows soft, symmetrical, and nontender breasts. There are no palpable masses and no axillary adenopathy. Which of the following is most appropriate next step in management?

A) Exchange saline implants for cohesive gel implants
B) Order MRI
C) Perform en bloc removal of the implants
D) Perform stereotactic biopsy of capsule
E) Request autoimmune disease evaluation

Answer 17

The correct response is Option E.

Breast implant illness (BII) is a term used to describe a multitude of symptoms seen in patients with breast implants. These symptoms may include the following (as well as others): fatigue, anxiety, headaches, brain fog, anxiety, photosensitivity, hormonal issues, rash, and hair loss. There is no definitive link between these symptoms and breast implants. Research is ongoing.

It is important that all patients with these symptoms are evaluated. BII has been self reported by patients with all types of implant characteristics including silicone, saline, textured surfaces, and smooth-walled implants.

Before undergoing surgery, evaluation of these patients is important. Many of these symptoms can be associated with known autoimmune diseases and should be evaluated for this possibility, either by a rheumatologist or other medical professional. If a known autoimmune disease is diagnosed, then traditional treatment for this known disease should be tried before explantation surgery.

Women who underwent explantation for possible BII had varying degrees of improvement including no improvement, temporary improvement, and permanent resolution of symptoms. In one study, patients with documented autoimmune disease showed no improvement following explantation.

MRI would not initially be needed with a normal physical examination and saline implants.

Stereotactic biopsy would be indicated for palpable masses or breast mass evaluation, not symptoms of BII.

References

Question 18

A 43-year-old woman presents with moderately large breasts with mild ptosis, and the surgical plan is a bilateral periareolar mastopexy to minimize the length of surgical scars. Which of the following postoperative complications is most commonly associated with this technique?

A) Areolar spreading
B) Constriction of the lower pole of the breast
C) Loss of nipple-areolar sensation
D) Pseudoherniation of the nipple-areolar complex
E) Synmastia

Answer 18

The correct response is Option A.

Mastopexy is a procedure designed to improve the appearance of the ptotic breast. The goal is to improve breast shape while minimizing visible scars. The periareolar mastopexy is best suited for correcting very minimal degrees of mammary ptosis. When the procedure is used to attempt to correct moderate to severe ptosis, complications can occur. These include flattening of the central breast mound; widening of the areolar diameter; and irregularity, widening, and even hypertrophy of the circumareolar surgical scar. Additionally, recurrent ptosis, or “bottoming out,” of the breast can occur.

Areolar spreading is the most common complication of this technique. Loss of nipple-areolar sensation is associated with breast tissue resection. Synmastia is associated with large implants, and pseudoherniation of the nipple areolar complex and constriction of the lower pole of the breast are associated with the tuberous breast deformity.

Question 19

A 31-year-old woman with micromastia comes to the office to discuss bilateral augmentation mammaplasty. Which of the following surgical plans will most likely minimize the risk for breast implant–associated anaplastic large cell lymphoma?

A) Highly cohesive silicone gel
B) Nipple shields
C) Saline implants
D) Smooth wall implants
E) Subpectoral pocket

Answer 19

The correct response is Option D.

It is extremely rare, if ever seen, to have a diagnosis of breast implant–associated anaplastic large cell lymphoma (BIA-ALCL) in a smooth implant–only case. In those BIA-ALCL cases with smooth wall implants, the patient’s past surgical history revealed the use of textured implants (where adequate documentation was available).

Aggressive texturing (macrotexturing) is associated with a higher risk for BIA-ALCL. One theory is related to increased surface area and therefore higher numbers of bacteria.

The most common presentation for BIA-ALCL is a patient presenting with a late seroma (usually greater than one year). Workup requires aspiration of the seroma followed by cytologic evaluation of the fluid and flow cytometry looking for CD30 T-cell surface protein, which is an ALCL tumor marker.

Highly cohesive silicone gel, saline implants, and the type of implant pocket do not significantly impact the incidence of BIA-ALCL.

Nipple shields and antibacterial irrigation can lower the incidence of bacterial contamination and MAY play a part in reducing biofilm, capsule contracture, and possibly BIA-ALCL. This impact on BIA-ALCL is unknown and being investigated. There are multiple documented cases of BIA-ALCL in patients with textured implants who underwent antibacterial irrigation to reduce bacterial contamination. Nonetheless, avoiding textured implants is the most likely strategy for minimizing BIA-ALCL.

Question 20

A 32-year-old woman is evaluated 4 years after undergoing bilateral augmentation mammaplasty with 375-mL, textured, shaped gel implants. She is concerned because over the past 3 months her left breast has grown one cup size larger than her right. On examination, there is no erythema or palpable mass. The left breast is much larger and firmer than the right. The patient started taking an oral contraceptive 6 months ago. Which of the following is the most likely diagnosis?

A) Breast implant–associated anaplastic large cell lymphoma
B) Capsular contracture
C) Double capsule
D) Drug-induced breast hypertrophy
E) Phyllodes tumor

Answer 20

The correct response is Option C.

This patient presents with a late seroma (more than 1 year after surgery) following augmentation mammaplasty with textured implants. The most common reason for this late seroma is a benign process related to the textured implant. A double capsule forms when the textured implant surface breaks away from its attachment to the breast parenchyma and forms a double capsule, which can then fill with blood or fluid. This phenomenon can be caused by a known trauma or in the course of daily living.

The possible etiologies for any late seroma include trauma, infection, inflammation, and malignancy. The first step in evaluation is ultrasound and aspiration of the fluid. The fluid should be evaluated for tumor markers (flow cytometry, CD30 T-cell surface protein) and sent for cytology and bacteriology.

This patient could have breast implant–associated anaplastic large cell lymphoma (BIA-ALCL). BIA-ALCL is rare, and it is highly unlikely that this patient has this lymphoma. Nonetheless, it must be ruled out. All patients presenting with a late seroma (more than 1 year after surgery) need to be evaluated for tumor markers. If the patient tests positive, full oncologic evaluation is needed.

Capsular contracture can cause hardening and deformity of the breast; however, it will not cause breast enlargement. A phyllodes tumor presents as a localized breast mass that can grow rapidly. This patient has no palpable masses.

Oral contraceptives can cause unilateral breast enlargement, but this patient is presenting with massive breast enlargement 6 months after starting birth control pills.

Question 21

A 45-year-old woman who underwent bilateral breast augmentation mammaplasty returns to the office after a motor vehicle accident with deployment of airbags. Physical examination shows point tenderness over the chest with an obvious “seat belt” sign along the left breast. The immediate diagnostic workup of the implants shows no rupture. Six months later, the patient returns with distortion of the left breast over the implant with a cleft formation. Which of the following is the most appropriate next step in assessing the integrity of the implants?

A) Chest x-ray study
B) CT scan with intravenous contrast
C) Mammography
D) MRI
E) Ultrasound

Answer 21

The correct response is Option D.

The patient has a late presentation of seat belt syndrome, which requires an MRI to assess the integrity of the breast implants. Patients with seat belt syndrome may present with a cleft or a mass. It is important to rule out invasive ductal carcinoma located in the line of the diagonal contracture. An intracapsular seroma can form gradually over time as well. Reconstructive options include unilateral capsulectomy and implant exchange.

Chest x-ray study can be used in a more immediate setting to rule out any bony injury to the chest wall. Mammography is an appropriate choice in patients who have a palpable mass in an initial assessment; however, this does not rule out implant rupture. In the event that there is an expanding breast in the immediate setting, CT scan with intravenous contrast can be used to rule out possible arterial extravasation or pneumothorax. Ultrasound can be used to assess implant or capsule rupture, but MRI is the most definitive investigative study.

Question 22

A 45-year-old woman is evaluated because of asymmetry of the chest during physical activity. Medical history includes bilateral augmentation mammaplasty with silicone implants approximately 10 years ago. She recently began an aggressive exercise regimen that includes long-distance running and weight training. The patient’s major aesthetic concern is that the implants distort the appearance of her breasts during weight training exercises. Which of the following is the best treatment for this patient?

A) Remove and replace the implants with more cohesive silicone gel implants
B) Remove and replace the implants with saline implants
C) Remove the implants and insert them in the subglandular plane
D) Remove the implants and insert them in the subpectoral plane
E) Remove the implants, perform bilateral capsulectomy, and insert new silicone implants

Answer 22

The correct response is Option C.

Muscle contraction deformity and implant displacement are corrected with the removal of the implant and placement into a newly created subglandular plane from the current subpectoral plane. The deformity described is typical in patients involved in heavy weight training in which the pectoralis muscle is repeatedly activated.

Moving the implants from the subpectoral plane into the subglandular plane will compress the subpectoral pocket, thus preventing movement into the previous pocket. In addition, the pectoralis muscle may be resuspended to prevent fluid accumulation.

Removal and replacement of the implants with more highly cohesive implants may improve any rippling that may be seen, but it will not improve the animation deformity. Removal and replacement with saline implants will not make any significant improvements in the muscle-induced deformity. While capsulectomy may improve capsular contraction, it does not address the deformity cause by repeated pectoralis activation.

Question 23

A healthy 45-year-old woman presents for consultation for mastopexy. Examination of the breasts shows grade II ptosis, large areolae, and dense breast tissue. No prior surgical scars are noted. An inverted T mastopexy is planned. On the day of surgery, the angle of the vertical limbs has to be marked wider than anticipated because of the large areolae. The large angle of divergence of the vertical limbs most likely increases the risk for which of the following?

A) Lower pole deformity
B) Nipple-areola malposition
C) Nipple-areola slough
D) Parenchymal fat necrosis
E) Pedicle overresection

Answer 23

The correct response is Option A.

For a patient undergoing a full-scar, inverted T skin resection as part of mastopexy, large areolae may require that the vertical limbs diverge more widely than would otherwise be necessary to tighten excess skin. This can create lower pole deformities such as flattening or boxiness.

The position of the nipple-areola complex is usually set at the Pitanguy point—the level determined by transposition of the inframammary crease onto the breast—and is not affected by large areolae in a patient who is a candidate for inverted T mastopexy. Necrosis of tissues such as the nipple-areola complex or breast parenchyma relate to surgical technique and preservation of blood supply to these areas. Pedicle overresection can lead to nipple-areola necrosis and is a result of poor surgical technique in developing the pedicle; pedicle design and resection are independent from the design of skin resection, as seen in this patient.

Question 24

A 27-year-old woman who underwent augmentation mammaplasty with 325-mL textured prostheses one year ago comes to the clinic because her breasts look asymmetric and feel hard. Physical examination shows firm asymmetric breasts with palpable capsules. No pain, signs of skin infection, hematoma, or seroma are observed. Hypertrophic scars are seen on the inframammary fold of both breasts. Which of the following factors is the most likely cause of capsular contracture in this patient?

A) Implant size
B) Patient history of hypertrophic scarring
C) Subclinical infection with biofilm formation
D) Submuscular positioning of the implants
E) Textured implants

Answer 24

The correct response is Option C.

On the basis of her clinical presentation, this patient is experiencing Baker Grade III capsular contracture. Capsular contracture is the most common complication after breast implant placement. This is a multifactorial complication; however, only subclinical infection with biofilm formation has a clear correlation with a higher degree of capsular contracture.

Implant size is not directly associated with an increased risk for clinically significant capsular contracture, and it has been established that textured implants are associated with a decreased risk. There is no clear evidence of a relation between a patient’s tendency to scar and an increased risk for capsular contracture. It is accepted that submuscular placement leads to lower rates of capsular contracture than the subglandular technique.

Question 25

A 47-year-old woman who underwent bilateral augmentation mammaplasty with silicone implants to treat mammary hypoplasia 17 years ago is evaluated because of worsening pain, firmness, and distortion of her breasts. Which of the following diagnostic evaluations is most sensitive for evaluating this patient's silicone breast implants? A) Breast thermography B) CT scan C) Mammography D) MRI E) Ultrasonography

Answer 25

The correct response is Option D. MRI scan would be the most sensitive and specific method for detection of silent rupture of a silicone breast implant in this patient. Classic MRI findings indicating rupture include the linguini sign or the teardrop sign. Current FDA recommendations are to obtain MRI screening for silent rupture three years after placement of silicone implants and every two years after that. CT scanning can show findings similar to those seen with MRI, but CT involves ionizing radiation, which can be harmful. CT has not been proven to be as sensitive as MRI in evaluating silicone breast implant rupture. Ultrasonography is a less costly method of implant evaluation but this method is highly operator-dependent. In asymptomatic women, a subsequent MRI scan is generally needed to confirm a positive ultrasound screen. Mammography is indicated for screening for breast cancer but not for implant rupture. Breast thermography utilizes digital infrared imaging to evaluate metabolic activity and vascular circulation of the breast to look for suspicious signs of breast cancer. It is not effective in the evaluation of silicone breast implant rupture.

Question 26

A 34-year-old woman with a history of grade I breast ptosis who is 6 years status post-augmentation mammaplasty with subglandular gel-filled implants returns to the clinic. Physical examination shows normal-appearing breasts, but there is mild firmness on palpation. Which of the following Baker grades best describes these findings? A) Grade I B) Grade II C) Grade III D) Grade IV

Answer 26

The correct response is Option B. Many classification systems have been used to evaluate the severity of breast capsular contracture, which occurs when the peri-implant capsule undergoes fibrotic change. The most widely employed assessment tool remains the Baker grading system, which takes into account patient signs and symptoms. According to the Baker classification, only the highest degrees of contractures (grades III and IV) require surgical treatment. The descriptors for each grade are listed here: Grade I: the breast is soft and appears normal in size and shape Grade II: the breast is a little firm and appears normal Grade III: the breast is firm and appears abnormal Grade IV: the breast is firm, appears abnormal, and is painful Studies note decreased relative risk for Baker grade III to IV capsular contracture in patients who undergo primary breast augmentation through an inframammary fold incision, subpectoral pocket placement, and textured implants. There is an increased relative risk for capsular contracture when patients undergo a periareolar or axillary incision and subglandular placement of smooth implants.

Question 27

A 36-year-old woman is evaluated because of spontaneous galactorrhea 6 days after undergoing augmentation mammaplasty. Which of the following factors most likely contributed to this outcome? A) Inframammary placement of the incision B) Subglandular versus dual-plane position of the device C) Surgical interruption of the intercostal nerves D) Use of silicone versus saline breast implants

Answer 27

The correct response is Option C. Although no one knows exactly what leads to postoperative galactorrhea, it is observed to occur more often in parous women and theorized to occur due to a combination of factors which simulate suckling or change in the innervation of the chest wall and nipple-areola complex. This would include increased tissue pressure related to the implant placement and interruption of intercostal nerves. No relationship has been identified between incision placement (peri-areolar, inframammary, transaxillary, or even peri-thelial) and postoperative galactorrhea. Similarly no relationship has been identified between device positioning (dual-plane, subglandular, and submuscular) and postoperative galactorrhea. Again, no relationship has been observed in implant type, saline versus silicone, and postoperative galactorrhea.

Question 28

A 23-year-old woman comes to the office because she is interested in augmentation mammaplasty. Physical examination shows a right-sided sunken anterior chest wall, hypoplasia of the right breast with a superiorly placed nipple-areola complex, normal pectoralis muscle, and normal sternal position. This patient most likely has which of the following congenital deformities? A) Amastia B) Anterior thoracic hypoplasia C) Pectus carinatum D) Pectus excavatum E) Poland syndrome

Answer 28

The correct response is Option B. Amastia refers to an uncommon developmental condition in which the breast and nipple are absent. Some women are immediately given the diagnosis of Poland syndrome or pectus deformity when they exhibit abnormalities of the anterior chest wall. Poland syndrome involves an abnormal pectoralis muscle while pectus deformities do not. Pectus deformities involve alteration in the appearance or location of the sternum and its costal attachments. Another less commonly realized diagnosis is that of anterior thoracic hypoplasia in which patients share the same characteristics of unilateral sunken anterior chest wall, hypoplasia of the breast, superiorly placed nipple-areola complex, normal pectoralis muscle, and normal sternal position.

Question 29

A 40-year-old woman comes to the office for consultation on an augmentation mastopexy 2 years after giving birth to her second child. She is back to her pre-pregnancy weight. Physical examination shows involutional changes contributing to a deflated appearance of the breasts. This appearance is most likely due to a histologic decrease in which of the following? A) Area composed of stromal matrix B) Number of differentiated lobules C) Thickness of dermis D) Thickness of pectoralis muscle E) Volume of adipose tissue

Answer 29

The correct response is Option B. Postpartum involutional changes can manifest clinically as breasts that appear deflated, commonly due to a loss of volume and skin that has been stretched. On a histologic level, these clinical manifestations occur due to a decrease in the number and area of differentiated lobules that were enlarged and specialized for milk production. As this occurs, it is hypothesized that the lobular area is then replaced by stromal matrix and eventually fat. Involutional changes do not refer to changes in the dermis, pectoralis muscle or chest wall structures.

Question 30

A 26-year-old healthy woman comes to the office for consultation because she has constant pain 1 year after undergoing augmentation mammaplasty by another surgeon. She reports that he "botched" her surgery and that she is considering taking legal action against him. On physical examination, the breasts are quite firm and mildly tender. The relatively immobile subglandular implants are high on the chest wall. There are no overlying skin changes. Which of the following is the most appropriate response by the surgeon in this scenario? A) Decline to establish care B) Follow-up visit in one year C) Perform a diagnostic intercostal nerve block D) Prescribe a course of oral corticosteroids E) Recommend surgical intervention

Answer 30

The correct response is Option E. This patient has developed Baker grade IV capsular contracture as evidenced by hard, painful breast implants that are malpositioned. This is a known complication of augmentation mammaplasty, and the patient should be informed that it is treatable with another surgery. It would be reassuring to the patient to hear that it is a known post-operative complication that happens not uncommonly, and that it is unlikely the other surgeon directly did anything to cause this. Thoughtful analysis and contextualization are helpful in high-tension consultations such as these. Providing the patient with a malpractice attorney's contact information may be what she thinks she wants, but diffusing the situation is best for all involved. Dismissing the patient's concerns outright without diagnosing her and suggesting a course of treatment would not be helpful. The new surgeon may even take it a step further by offering to speak with her previous surgeon to discuss the patient's concerns and the findings seen during consultation. The patient may refuse to allow this, and she may have lost faith in her other surgeon, but at least offering to speak with the other surgeon is prudent and may restore the relationship between this patient and her surgeon. A pain management specialist and physical therapy may help somewhat with symptoms, but her problem ultimately requires and should respond well to a surgical solution.

Question 31

A 39-year-old woman comes to the office with a 6-month history of progressive firmness and superior fullness of the left breast. History includes bilateral augmentation mammaplasty with textured saline implants placed in a submuscular dual-plane pocket 15 years ago. On physical examination, the left breast appears larger and firmer with more upper pole fullness in comparison with the right breast. Which of the following is the most appropriate next step? A) Capsulectomy and pocket change B) Mammography C) 3-Month trial of montelukast (Singulair) D) MRI E) Ultrasonography

Answer 31

The correct response is Option E. Breast implant patients who present with late-onset enlargement of one of their breasts require evaluation for breast implant-associated anaplastic large cell lymphoma (BIA-ALCL). This disease usually presents with spontaneous onset of peri-prosthetic fluid. A late-onset seroma is usually accepted as occurring 1 year after surgery; however, they have presented as early as 4 months. It is often difficult to determine if late-onset firmness of the implant is secondary to fluid, capsular contracture, or both. The initial workup should begin with an ultrasound to evaluate for peri-prosthetic fluid or capsular mass. If fluid is present, it should be sent for cytology, flow cytometry with immunohistochemistry looking for expression of T-cell CD30 cell surface protein. BIA-ALCL is overwhelmingly associated with textured implants. It is important to remember that BIA-ALCL is extremely rare and that most patients presenting with a late seroma will not have lymphoma, but will have peri-prosthetic fluid from the textured surface pulling away from the capsule and forming a double capsule. The treatment for localized BIA-ALCL is bilateral total capsulectomy and explantation. Treatment for the more likely double capsule or capsule contracture is capsulectomy and pocket change; however, surgery is not indicated until the diagnosis is made. Montelukast is a leukotriene antagonist that can inhibit the inflammatory cascade thought to be involved with capsular contracture. It seems to be more useful in patients with capsular contracture less than grade III. There is no consensus on its use or effectiveness. The sensitivity and specificity of ultrasound for detecting a seroma has been equal or better than MRI or 3D mammography. After diagnosis of ALCL, MRI and PET scanning may be indicated. If the implants were silicone gel, MRI would be indicated to evaluate for implant rupture; however, ultrasound would still be recommended for seroma evaluation and aspiration.

Question 32

An otherwise healthy 25-year-old woman is evaluated and scheduled for augmentation mammaplasty with silicone gel implants. Which of the following is most accurate regarding breast implant-associated anaplastic large cell lymphoma (BIA-ALCL)? A) All late breast implant-associated seromas should be evaluated B) BIA-ALCL is most often associated with an aggressive clinical course C) BIA-ALCL is most often associated with smooth implants D) It is not necessary to include BIA-ALCL in a standard breast augmentation/reconstruction consent E) Knowledge about BIA-ALCL's cause is based on strong evidence-based studies

Answer 32

The correct response is Option A. Due to the potential critical relevance of breast implant-associated anaplastic large cell lymphoma (BIA-ALCL) and its tendency to present as a late seroma, correct diagnostic pathways should be carried out on all late breast implant-associated seromas to include cytologic examination and, if indicated further, fine-needle aspiration, flow cytometry, and immunohistochemistry for CD30. BIA-ALCL is a critical outcome in implant-associated breast augmentation/reconstruction. It is most commonly confined to peri-implant seroma fluid and follows a nonaggressive course amenable to implant and capsule removal, although there are aggressive variants. Discussion about this condition should be part of the consenting process for all breast implant cases. Finally, to this point evidence on cause is based on very low-evidence studies. ALCL is most often associated with textured implants.

Question 33

A 55-year-old woman who underwent augmentation mammaplasty with retro-pectoral smooth saline implants 18 years ago comes to the office because she is dissatisfied with her breast shape. Physical examination shows glandular ptosis hanging off the implants. She has Grade I capsules. Which of the following is the most appropriate procedure to correct this patient's deformity? A) Implant exchange alone B) Implant exchange with capsulectomy C) Implant exchange with mastopexy D) Implant exchange with suture plication of the expanded inferior pocket E) Site change to subglandular placement

Answer 33

The correct response is Option C. The described patient has a "snoopy nose deformity" or "waterfall breast deformity," with the ptotic breast hanging off of the implant. There is no pocket expansion. The implants have stayed in their original position while the native breast tissue has become ptotic with time and gravity. This is not superior malposition due to capsular contracture; both breasts are soft. Correction of this problem is best performed with an appropriately chosen form of mastopexy. In this case, replacement of the implants would also be performed because of their age. Implant exchange alone would not correct the ptotic breast. Capsulectomy is not indicated, since the breasts are soft, and no capsule is noted clinically. Similarly, suture plication of the pocket is not required, since the inframammary fold is in the correct position, and no second fold is seen. Site change would not correct the patient’s grade III ptosis, but it may be used to correct this problem in cases without significant ptosis.

Question 34

A 28-year-old postpartum woman comes to the office for evaluation of breast asymmetry with pain and enlargement of the right breast for 2 months. Medical history includes augmentation mammaplasty 4 years ago. She denies fever or chills. She was previously breast-feeding but stopped this 1 month ago. Physical examination shows the right breast is significantly larger than the left breast. A well-healed peri-areolar incision is present and no evidence of infection is noted. Ultrasound shows a complex cyst, which yields 150 cc of milky fluid. A drain is placed. The most appropriate next step is administration of which of the following medications? A) Bromocriptine B) Cephalexin C) Fluconazole D) Prolactin E) Trimethoprim-sulfamethoxazole

Answer 34

The correct response is Option A. This postpartum patient is presenting with a symptomatic galactocele after breast-feeding. Galactoceles are benign breast cysts containing milk. They typically occur in women of childbearing age in the setting of active lactation, recent pregnancy, or the use of hormonal medications such as oral contraceptives. The galactocele is thought to occur from ductal obstruction. Although the presence of a breast implant and the respective pocket placement is unknown to have an effect on the development of galactoceles, there is some thought that peri-areolar incisions may contribute to the ductal obstruction. There are, however, documented cases of post-augmentation galactocele without peri-areolar incisions. Treatment for a galactocele is typically medical with the initiation of oral bromocriptine. Bromocriptine is a dopamine receptor agonist and causes inhibition of prolactin secretion, which is the primary hormone responsible for milk production. Dosage is titrated to effect. Incision and drainage of the cyst, particularly in the setting of implants, is often performed as well to rule out the possibility of infection. Cephalexin and trimethoprim-sulfamethoxazole are antibiotics and are not indicated in this case because there is no active infection. Fluconazole is indicated for the treatment of fungal infections. Prolactin would actually stimulate milk production and would worsen the patient's symptoms.

Question 35

A 54-year-old woman with a history of augmentation mammaplasty with textured silicone implants has histologic confirmation of breast implant–associated anaplastic large cell lymphoma (BIA-ALCL). MRI and PET scans show no associated masses, with activity localized to the periprosthetic seroma. Which of the following is the most appropriate next step in management of this patient? A) Anterior capsulectomy with removal of the implants bilaterally B) Complete capsulectomy with removal of the implant on the affected side C) Partial capsulectomy with replacement of the implant D) Removal of the textured implant and replacement with a smooth implant E) Sealing of the seroma cavity with fibrin glue

Answer 35

The correct response is Option B. Breast implant–associated anaplastic large cell lymphoma (BIA-ALCL) is a rare peripheral T-cell lymphoma that has been increasingly recognized as a serious, albeit uncommon, complication associated with the use of textured breast implants. Since the initial case report in 1996, there have been continually increasing reported cases of this rare malignancy and according to the most recent data available, the lifetime risk of association between breast implants and BIA-ALCL is between 1 in 1000 to 1 in 30,000 with the ASPS recognizing nearly 200 cases in the US and nearly 500 cases worldwide. BIA-ALCL patients typically present with a spontaneously occurring periprosthetic fluid collection or capsule-associated mass approximately 10 years following implantation of the breast implant. To date, all cases have had some association with a textured device. Initial workup includes ultrasound for evaluation of a periprosthetic fluid collection or mass. Periprosthetic fluid collections should undergo fine-needle aspiration in the clinic or ultrasound-guided aspiration by interventional radiology if there is concern for trauma to the implant while masses require tissue biopsy. Specimens should be sent for cytology with immunohistochemistry and flow cytometry for T-cell markers, specifically CD30 cell surface protein. A recent systematic review revealed that 66% of BIA-ALCL patients presented with isolated late-onset seroma while only 8% presented with an isolated new breast mass. National Comprehensive Cancer Network (NCCN) guidelines for treatment of BIA-ALCL recommend complete removal of the lymphoma (fluid and/or mass), complete capsulectomy, and removal of the implant. More advanced disease may require chemotherapy, radiotherapy, and/or lymph node dissection. Although some surgeons advocate removal of the contralateral breast implant as approximately 4.6% of cases have demonstrated incidental lymphoma in the contralateral breast, this recommendation is controversial. The official NCCN guidelines for treatment only recommend consideration of contralateral breast implant removal but this is not mandated.

Question 36

A 48-year-old woman, gravida 3, para 3, who wears a size 36B bra comes to the physician for evaluation of breast ptosis. BMI is 24 kg/m2. Physical examination shows the distance from sternal notch to nipple is 28 cm, and there is grade 2 breast ptosis with skin laxity. A combined augmentation/mastopexy is planned. Which of the following is the biggest risk of combining the procedures rather than staging them? A) Hematoma B) Need for revision procedure C) Nipple-areola complex necrosis D) Seroma E) Transection of lateral intercostal nerves

Answer 36

The correct response is Option B. Combining an augmentation with a mastopexy has long been considered risky because the surgeon is addressing two opposing forces during the same operation: the ptosis and volume, for which the placement of additional weight may exacerbate ptosis. Studies have shown, however, that the two operations can safely be combined. During the planning, particularly for severe ptosis, the surgeon must be careful not to overresect skin that will be critical for closure over an implant. Compared with staged procedures, mastopexy-augmentation has a higher rate of need for revision procedures. Patients should be counseled about the potential need for revisions. Seroma and hematoma are not increased when combining the procedures, and nipple-areola complex necrosis is a function of pedicle size and patient-specific factors such as obesity and tobacco use, rather than the combination of procedures. Similarly, transection of intercostal nerves is associated more closely with pedicle type than with combining procedures.

Question 37

Which of the following cell types is most associated with the chronic inflammation that leads to breast implant–associated anaplastic large cell lymphoma? A) B-cells B) Monocytes C) Neutrophils D) Red blood cells E) T-cells

Answer 37

The correct response is Option E. Evidence suggests that chronic inflammation is the stimulus responsible for the development of breast implant–associated anaplastic large cell lymphoma (ALCL) and T-cells are the predominant cell type responding to this antigenic stimulus. B-cells have been implicated in orthopedic implant lymphomas. The other cell types are involved in inflammation, but they are not associated with breast implant-associated ALCL.

Question 38

A 38-year-old woman reports decreased areola sensitivity after undergoing mastopexy. Intraoperative injury to which of the following nerves is the most likely cause of this patient's reduced sensitivity? A) Intercostobrachial nerve B) Lateral cutaneous branch of the fourth intercostal nerve C) Lateral cutaneous branch of the sixth intercostal nerve D) Medial cutaneous branch of the fifth intercostal nerve E) Medial cutaneous branch of the third intercostal nerve

Answer 38

The correct response is Option B. The lateral cutaneous branch of the fourth intercostal nerve is most commonly responsible for nipple and areola sensitivity. The other intercostal nerve branches listed do contribute to breast sensitivity but are less often thought to be the primary innervation to the nipple and areola. The intercostobrachial nerve supplies innervation to the upper medial arm.

Question 39

A 47-year-old woman, gravida 2, para 2, who has grade III breast ptosis is evaluated for mastopexy. Attenuation of which of the following structures is the most likely cause of the ptosis? A) Breast acini B) Cooper ligaments C) Lactiferous ducts D) Scarpa’s fascia E) Subdermal plexus

Answer 39

The correct response is Option B. Breast ptosis is a complex interaction of events, informed by breast size, gravity, aging, lactation, and parity. It occurs through a combination of atrophy of the breast tissue, loss of elasticity of the skin envelope, and attenuation of Cooper ligaments. While the breast is surrounded by fascia, the continuation of Scarpa’s fascia forms the posterior capsule of the breast. The lactiferous ducts and breast acini do not contribute significantly to ptosis. Subdermal plexus provides vascularity rather than support to the breast.

Question 40

A 24-year-old woman comes to the office to discuss augmentation mammaplasty. She is interested in subglandular implant placement and would like to discuss the risks of augmentation. Which of the following risks is more likely with smooth round silicone implants compared with textured anatomic silicone implants? A) Anaplastic large cell lymphoma B) Capsular contracture C) Double capsule D) Late seroma E) Malrotation

Answer 40

The correct response is Option B. Capsular contracture is more common in smooth round silicone implants than in textured implants. It is believed that the texturing of the implant is protective against significant capsule formation. On the other hand, there are several increased risks associated with textured anatomic implants. These include increased risks of late seroma and breast implant-associated anaplastic large cell lymphoma (BIA-ALCL), although this is very rare. Double capsule is a complication more recently noted with the introduction of textured anatomic implants. Malrotation can only be seen in an anatomic textured implant, because smooth round implants are symmetric in shape. In addition, it can be difficult to differentiate between anatomic shaped and smooth round implants, with several studies showing their similar cosmetic

Question 41

A 23-year-old woman undergoes augmentation mammaplasty with round, smooth silicone implants placed in the dual-plane position. Postoperatively, unilateral erythema and warmth are noted, and they slowly resolve over 10 days of oral antibiotic treatment. The patient asks what this might mean for future satisfaction with the outcomes. Which of the following is the most likely sequela of this patient's clinical course? A) Breast gland ptosis B) Capsular contracture C) Double-bubble appearance D) Implant rupture E) Nipple numbness

Answer 41

The correct response is Option B. One of the most often mentioned potential risk factors for capsular contracture is biofilm, and this may be related to bacterial contamination. History of infection is unlikely to impact nipple sensation, implant rupture, true breast gland ptosis, or effacement of the inframammary fold with downward descent of the implant.

Question 42

In women with breast ptosis, which of the following is an advantage of performing combined one-stage augmentation mammaplasty with mastopexy compared with mastopexy alone? A) Better predictability of cosmetic outcome B) Decreased complication rates C) Decreased revision rates D) Improved upper pole projection E) Lower operative costs

Answer 42

The correct response is Option D. Early reports have raised concerns about the safety of combined augmentation mammaplasty with mastopexy surgeries. However, in patients who wish to correct their breast ptosis these two procedures are often combined to a one-stage surgery and can show favorable outcomes. Nevertheless, plastic surgeons advocate that these cases should only be performed by experienced physicians. Reasons are that the overall aesthetic results are harder to predict in one-stage augmentation/mastopexy procedures compared to mastopexy alone or even the two-stage augmentation mammaplasty followed by mastopexy. Both complication and revision rates are highest in the one-stage approach that combines augmentation mammaplasty with mastopexy. Longer operative time and the need for implants naturally increase operative costs. The advantage of the simultaneous insertion of implants is the improved superior pole projection that cannot be achieved by mastopexy alone.

Question 43

In grade II ptosis of the breast, which of the following best describes the position of the nipple? A) At the apex of the breast mound B) At the lowest contour of the breast C) At the transposed inframammary fold D) Between the inframammary fold and the lowest contour of the breast E) On the posterior aspect of the breast as it rests on the chest wall

Answer 43

The correct response is Option D. The classic Regnault definition of breast ptosis classifications are as follows: Grade I: Nipple at the level of the inframammary fold Grade II: Nipple between the level of the inframammary fold and the lowest contour of the breast Grade III: Nipple at the lowest contour of the breast

Question 44

A 35-year-old woman is evaluated for long-term follow-up 9 years after undergoing bilateral augmentation mammaplasty for hypomastia by another surgeon. The mammaplasty was performed with 450-mL smooth, round, silicone subglandular implants. The patient recently found out she is BRCA2 positive and underwent MRI of the breasts as part of a surveillance study. The MRI showed a "linguine sign" in the right breast. Which of the following findings on physical examination is most consistent with the diagnosis associated with the "linguine sign"? A) The right breast has more rippling than the left breast B) The right breast is not significantly different from the left breast C) The right breast is significantly larger than the left breast D) The right breast is significantly smaller than the left breast

Answer 44

The correct response is Option B. The right breast is not significantly different from the left breast. The linguine sign describes multiple low-signal curvilinear lines on MRI that correlated to the collapsed implant shell. It is an indication of intracapsular rupture. Physical examination alone is not specific or sensitive enough to diagnose all cases of intracapsular rupture. Ultrasound and/or MRI is recommended. The physical examination finding of one breast that is smaller, firmer, and higher than the other is indicative of capsular contracture. MRI is not a sensitive predictor of capsular contracture. A right breast that is significantly larger than the left breast would indicate a late seroma and a workup for breast implant-associated anaplastic large-cell lymphoma would be indicated. A right breast that is significantly smaller than the left breast would be indicative of a ruptured saline implant. Increased rippling is not expected with an intracapsular rupture.

Question 45

A 40-year-old woman who underwent a subglandular augmentation mammaplasty with smooth round silicone breast implants 5 years ago returns to the office for evaluation of an increasingly firm left breast. Surgical revision of the left breast is planned. Which of the following measures is most likely to decrease the recurrence of the symptoms? A) Conversion to a new plane or pocket B) Performing a total capsulectomy C) Using botulinum toxin type A in and around the implant pocket D) Using fat grafting in and around the implant pocket

Answer 45

The correct response is Option A. Site change and implant exchange are the only factors that have consistently been shown to decrease recurrence of capsular contracture, although other factors including use of a textured implant and fat grafting used are in augmentation mammoplasty revision. Botulinum toxin type A has been described for prevention of capsular contracture however; no consensus that these treatments decrease recurrence of capsular contracture exists. Furthermore, there are no data to support performing total versus partial capsulectomy, or even the superiority of capsulectomy over capsulotomy.

Question 46

A patient comes to the office 6 months after undergoing bilateral vertical mastopexy because she is dissatisfied with her postoperative appearance. Height is 5 ft 5 in (165 cm). Physical examination shows the distance from nipple to sternal notch is 16 cm bilaterally, and the distance from nipple to inframammary fold is 14 cm bilaterally. Which of the following is the most appropriate next step in management? A) Conversion to free nipple grafts B) Placement of a dual-plane breast implant C) Placement of a subglandular breast implant D) Resection of excess skin at the level of the inframammary fold E) Reassurance, massage, and observation

Answer 46

The correct response is Option D. This case illustrates superior nipple malposition. The distance from nipple to inframammary (IMF) fold of 14 cm is much too long. The correct answer is to resect the lower pole skin at the IMF in order to move the nipple down. This would create a "T" scar and improve nipple position. Vertical mastopexies and reduction mammaplasties have a learning curve and much of this is predicting the nipple position postoperatively. The nipple should be designed lower on the breast than is done during marking a Wise pattern. At 6 months, it is unlikely the nipple position will change dramatically, so observation is not recommended. Addition of an implant will not help the nipple position. Conversion to free nipple grafts, while possible, will not lead to an aesthetic scar pattern.

Question 47

A 23-year-old woman with micromastia and bilaterally tuberous breasts comes to the office to discuss augmentation mammaplasty and improving the overall appearance of her breasts. Physical examination shows bilateral mildly ptotic breasts with glandular tissue herniating through the nipple-areola complex. The lower pole appears mildly deficient in the lower medial and lateral quadrants, and the distance from the nipple to the inframammary crease is 5.5 cm on stretch. Which of the following is the most appropriate operative approach for this patient? A) Implant placement with circumareolar mastopexy B) Implant placement without mastopexy C) Implant placement with vertical mastopexy D) Implant placement with Wise-pattern mastopexy E) Two-stage reconstruction with tissue expander, followed by placement of a permanent implant

Answer 47

The correct response is Option A. The tuberous breast deformity was first described by Aston and Rees in 1976. While most of the surgical approaches listed, with the exception of implants together with Wise-pattern mastopexy, have been described for the spectrum of tuberous breast deformities, the key is to select the right procedure for the right patient. In this case, a mild form of the deformity is described. Implant placement alone, even with parenchymal scoring and lowering of the inframammary crease, is unlikely to correct the deformity of the nipple-areola complex. In cases of severe ptosis, vertical mastopexy may be used but would be unnecessary in this patient with mild ptosis. In severely deficient cases, a two-stage approach with tissue expansion may be necessary, but it would be over-operating in this mildly deficient patient. Recently, fat grafting has also been advocated for this procedure. In the case described, which is a common presentation, a periareolar approach is typically used to place the implant in a dual-plane configuration. Subglandular placement is also described. The inframammary crease is commonly adjusted downward. Radial scoring of the parenchyma and a circumareolar mastopexy are typically performed. In the recent review by Kolker and Collins, 92% of tuberous breast patients had a one-stage procedure. Ninety-six percent of these were treated with implant placement and circumareolar mastopexy, combined with inframammary crease adjustment and radial scoring of the parenchyma.

Question 48

A 35-year-old woman is evaluated because of swelling of the right breast 3 years after undergoing augmentation mammaplasty. The implant type is unknown. Ultrasonography shows a seroma, and a fine-needle aspiration is performed. Which of the following immunohistochemical stains of the aspirate is most appropriate? A) CCD79a B) CD30 C) CK20 D) E-cadherin E) p63

Answer 48

The correct response is Option B. Patients who present with a late seroma should be evaluated for possible breast implant-associated anaplastic large cell lymphoma (BI-ALCL). A late seroma is usually accepted as occurring 1 year following surgery; however, there are cases of BI-ALCL seromas that have presented as early as 4 months. The first step in evaluating BI-ALCL is ultrasonography, followed by fine-needle aspiration if indicated. The fluid requires evaluation beyond routine cell cytology. Immunohistochemistry test for CD30 was the most commonly positive marker for BI-ALCL. Immunohistochemistry stains specific antigens in cells by binding to this antigen in an antibody/antigen reaction. The specific stain can then be seen under light microscopy. The CD30 antibody labels anaplastic large cell lymphoma cells. CD30 is a transmembrane cytokine receptor belonging to the tumor necrosis factor receptor family. CK20 and CCD79a were negative for tested BI-ALCL specimens. P63 stains myoepithelial cells and is used to rule out invasive breast tumors. E-cadherin helps distinguish ductal from lobular carcinoma.

Question 49

A 58-year-old woman with moderate ptosis is evaluated for mastopexy. According to Regnault classification, which of the following best describes the location of the nipple-areola complex in type II breast ptosis? A) 1 to 3 cm inferior to the inframammary fold B) 4 cm inferior to the inframammary fold C) 6 cm inferior to the inframammary fold D) At or 1 cm inferior to the inframammary fold E) Superior to the inframammary fold

Answer 49

The correct response is Option A. Regnault classification of breast ptosis, based on the position of the nipple-areola complex (NAC) relative to the inframammary fold (IMF): The type of mastopexy performed will depend on the degree of breast ptosis. Breast ptosis is graded using Regnault classification. Type I can be treated with a crescent mastopexy, when the degree of nipple-areola complex elevation does not exceed 1 cm. Type I or II ptosis can be treated with a periareolar mastopexy, when the distance of nipple-areola complex elevation ranges from 1 to 2 cm. Type II and III ptosis is amenable to the inverted-T technique, where the horizontal incision will reduce the distance from the nipple-areola complex to the inframammary fold, while the vertical incision will reduce the base diameter.

Question 50

A 28-year-old woman comes to discuss primary augmentation mammaplasty options and is deciding between form-stable shaped implants and less cohesive round silicone gel implants. She inquires about the benefits of each type of implant. Compared with smooth round silicone gel implants, highly cohesive form-stable gel implants have a decreased incidence of which of the following? A) Capsular contracture B) Implant malposition C) Infection D) Seroma

Answer 50

The correct response is Option A. Form-stable silicone gel implants are fifth-generation, shaped, and textured implants that have additional cross-linking between molecules. They are purported to have several advantages over other round saline and silicone gel implants because they retain their shape and decrease the incidence of folding and rippling. This has translated into significantly lower capsular contracture rates. However, they do have some disadvantages. Because they are shaped and maintaining orientation is critical, they have a higher incidence of malposition. They are also more prone to seroma formation, which may be associated with their textured surface. Infection and resorption rates remain similar.

Question 51

A 28-year-old woman comes to the office to discuss augmentation mammaplasty. She is interested in silicone implants, specifically highly cohesive gel shaped implants. Which of the following is the most likely result of increasing the cross-linking in these implants? A) Decreased risk of gel fracture B) Decreased risk of shell delamination C) Improved form stability D) Increased risk of folds E) Softer implants

Answer 51

The correct response is Option C. Increasing the cross-linking in a highly cohesive gel shaped silicone implant improves form stability. This allows for the creation of shaped implant designs that persist despite position or external forces on the implant. The current, fifth-generation silicone breast implants derive their cohesiveness from the cross-linking of the silicone. Increasing the amount of cross-linking leads to an increase in cohesiveness and a firmer implant. This may lead to less rippling and folding because of resistance to collapse; however, recent MRI studies have shown folds and distortions are still possible. Increasing cohesiveness, however, does have some disadvantages with potential risks for gel fracture and delamination of the implant shell.

Question 52

A 13-year-old girl is evaluated for breast asymmetry. Examination shows total absence of the left mammary gland tissue, with normal areola and nipple. Pectoral muscles are normal. No hand, facial, or other body abnormalities are noted. Which of the following is the most likely diagnosis? A) Amastia B) Amazia C) Athelia D) Ectodermal dysplasia E) Poland sequence

Answer 52

The correct response is Option B. There are a number of uncommon aplastic deformities of the breast. These include: total absence of the breast and nipple (amastia), absence of the nipple (athelia), and absence of the mammary gland (amazia), as described in this case. These anomalies may occur in isolation, or may be associated with various syndromes, such as Poland syndrome, where the absence of the breast is associated with absence of the pectoralis major muscle, rib cage and ipsilateral upper limb deformities. Ectodermal dysplasias can affect the breast, but two or more abnormalities of ectodermal structures – hair, teeth, nails, sweat glands, craniofacial structures – would be required to consider the diagnosis.

Question 53

A 48-year-old woman comes to the office because she is very unhappy with the appearance of her breasts following a bilateral mastopexy performed 1 year ago. Height is 5 ft 7 in (170 cm). BMI is 26 kg/m2. Which of the following findings on physical examination would be most difficult to correct? A) Asymmetrical breast size B) Dog ear of the inferior vertical scar C) Nipple to inframammary crease distance of 16 cm D) Nipple to sternal notch distance of 16 cm E) Widened circumareolar scar

Answer 53

The correct response is Option D. A sternal notch to nipple distance of 16 cm represents a high-riding nipple. Revisional surgery for correction of a high-riding nipple is complex, and it is difficult to achieve a favorable result because of the surgeon’s and patient’s desire to avoid a scar extending superior to the nipple areola. Further, the paucity of excess skin between the nipple and clavicle limits the reconstructive options. Suggested strategies include direct reposition of the nipple-areola complex, expansion of the skin between the nipple and clavicle, and repositioning of the breast parenchyma and inframammary crease. Breast size asymmetry can be improved with either liposuction or revision mastopexy/reduction. The operation is usually performed using the previous incisions. A dog ear of the inferior vertical scar is easily revised with a small transverse scar within the inframammary crease. The majority of these early postoperative deformities will resolve without surgery. Recurrence of ptosis or an elongation of the nipple to inframammary crease distance occurs with all mastopexy operations. When performing secondary mastopexy, this can be improved with shortening the vertical scar with wedge resection at the inframammary crease. Knowledge of the location of the previous nipple areola pedicle is helpful in minimizing vascular complications. Widened circumareolar scars can be revised with excellent results. Utilizing a permanent suture around the areola helps control size of the areola and tension on the suture line.

Question 54

The mammary glands develop from which of the following embryologic structures? A) Bilateral mesenchymal condensations B) Ingrowths from the ectoderm C) Ingrowths from the mesoderm D) Proliferating masses of endoderm E) Proliferating masses of mesenchyme

Answer 54

The correct response is Option B. The breasts, or mammary glands, are modified sweat glands. They are ingrowths from the ectoderm that form the lactiferous ducts and alveoli. They begin as linear mammary ridges with 15 to 20 buds. During the seventh week in utero, these buds undergo apoptosis, leaving a single pair of solid buds—the primary mammary buds—at the fourth or fifth intercostal space. Proliferating masses of mesenchyme are at the center of each limb bud. The mesoderm gives rise to organs, musculature, vasculature, and connective tissues. The endoderm becomes the epithelial lining of the alimentary tract. Bilateral mesenchymatous condensations develop into the sternum.

Question 55

A 22-year-old nulliparous woman is evaluated for improvement of breast shape and size. Examination shows bilateral hypoplastic breasts with constricted bases and herniation of breast parenchyma in the areolae. Tuberous breast deformity is diagnosed. Bilateral breast augmentation with smooth, round gel implants via periareolar incisions is planned. Which of the following maneuvers is most likely to decrease the risk for a "double-bubble" deformity? A) Decreasing the areolar diameter B) Lowering of the inframammary fold C) Parenchymal scoring D) Periareolar incision E) Subpectoral placement of the implant

Answer 55

The correct response is Option C. Common hallmarks of tuberous breast deformity include varying degrees of hypoplastic breast parenchyma, deficiencies of the inferior pole, herniation of the parenchyma in the areola, enlarged areolae, superior placement of the inframammary fold, and asymmetry. Surgical goals are to achieve symmetry, sufficient volume (especially in the hypoplastic areas), lowering of the inframammary fold, reduction of areolar tissue herniation, and correction of any ptosis. A double-bubble deformity can occur when the inframammary fold is not sufficiently obliterated. The risk for this is increased with superiorly displaced inframammary folds, as in tuberous breasts. Parenchymal scoring would both release any constricting bands to allow the lower pole tissue to spread over the implant as well as release the superiorly displaced inframammary fold. While decreasing the areolar diameter and lowering of the inframammary fold are goals for breast improvement, neither will treat a double-bubble deformity. A periareolar incision is often advocated in repair of tuberous breasts because of the ability to reduce the areola; it alone, however, will not prevent a double-bubble deformity. Subpectoral placement of implants increases the risk for double-bubble deformity while subglandular placement of implants decreases the risk. Many advocate a dual-plane approach to capitalize on increased upper pole coverage combined with the benefits of a subglandular relationship in the inferior pole.

Question 56

A 35-year-old woman, gravida 2, para 2, seeks implant-based augmentation mammaplasty. She breastfed both her children. Which of the following is the most common complication of this procedure? A) Early implant rupture B) Hematoma C) Infection D) Lifetime need for reoperation E) Seroma

Answer 56

The correct response is Option D. Augmentation mammaplasty is known to have high rates of complications including reoperation. Infection, seroma, hematoma, and early implant rupture are rare in elective, cosmetic augmentation mammaplasty.

Question 57

A 35-year-old woman, gravida 2, para 2, seeks implant-based augmentation mammaplasty. She breastfed both her children. Which of the following is the most common complication of this procedure? A) Early implant rupture B) Hematoma C) Infection D) Lifetime need for reoperation E) Seroma

Answer 57

The correct response is Option D. Augmentation mammaplasty is known to have high rates of complications including reoperation. Infection, seroma, hematoma, and early implant rupture are rare in elective, cosmetic augmentation mammaplasty.

Question 58

A 28-year-old woman is evaluated for micromastia. During consultation, she reports that her best friend underwent breast augmentation that was complicated by painful capsular contracture. Which of the following measures is most likely to prevent this complication in this patient? A) Initiation of implant massage on postoperative day 5 B) Placement of a closed suction drain for prevention of postoperative hematoma C) Use of a surgical support bra postoperatively for 2 weeks D) Use of a subglandular, smooth, round implant via periareolar incision E) Use of a subpectoral, textured implant via inframammary incision

Answer 58

The correct response is Option E. Capsular contracture occurs when there is fibrosis of the peri-implant capsule. The severity is typically described by the Baker Grade classification. Grade 1: the breast is soft and appears normal in size and shape Grade 2: the breast is a little firm and appears normal Grade 3: the breast is firm and appears abnormal Grade 4: the breast is firm, appears abnormal, and is painful Studies have shown a decreased relative risk for Baker grade 3-4 capsular contracture in primary breast augmentation associated with inframammary fold incision, textured implants, and subpectoral placement. The relative risk for capsular contracture was increased with periareolar or axillary incision, smooth implants, and subglandular placement. There is no evidence that wearing a support bra or implant massage will decrease the risk for capsular contracture. While hematoma is linked to capsular contracture, the presence of a drain does not prevent hematoma.

Question 59

A 47-year-old woman, gravida 3, para 3, is evaluated for improvement of breast appearance. She breast-fed all three of her children for 1 year each. Examination shows the distance from nipple to sternal notch is 27 cm bilaterally; decreased superior pole volume, and striae are also noted. There is Grade 3 ptosis bilaterally. The pinch of the superior pole soft tissue is 1 cm. Which of the following procedures is most likely to improve superior pole volume and breast shape in this patient? A) Dual-plane implant augmentation B) Mastopexy with dual-plane implant augmentation C) Mastopexy with subglandular implant augmentation D) Subglandular implant augmentation E) Vertical mastopexy

Answer 59

The correct response is Option B. Goals of improvement would be upper pole fullness and a coned, rounded breast, with raising the nipple. Because the superior pole thickness is less than 2 cm, a subglandular implant is not recommended. A dual-plane implant would not address the ptosis and would likely leave persistent ptosis. Vertical mastopexy alone would require some modification to address the excess vertical skin with some element of horizontal inferior excision. This would not address the lack of upper pole volume in the long term. The striae indicate poor tissue strength. Staged implant placement would have the fewest risks.

Question 60

A 55-year-old postmenopausal woman desires improvement in the appearance of her breasts. Change in which of the following levels of hormones is most likely responsible for postmenopausal involution of breast tissue? A) Estrogen B) Growth hormone C) Oxytocin D) Prolactin E) Testosterone

Answer 60

The correct response is Option A. Estrogen is the primary hormone in promoting the development of the breast epithelium and ductal tissue. Progesterone acts in combination with estrogen to regulate breast development. With the onset of menopause, there is a decrease in the secretion of estrogen and progesterone. As a result of the decrease in the circulating levels of these hormones, the breast undergoes regression and atrophy of the glandular elements. Oxytocin and prolactin are hormones involved in the physiology of lactation. Growth hormone and testosterone may have an effect on breast tissue, but they are not primary factors in the physiology of the female breast.

Question 61

A 28-year-old woman, gravida 2, para 2, undergoes augmentation mammaplasty 1 year post partum. On postoperative day 3, the patient comes to the office because of impaired wound healing at the incision site. Physical examination shows white viscous discharge leaking from the edge of the wound consistent with galactorrhea. Which of the following is the most appropriate management? A) Administration of bromocriptine B) Administration of metoclopramide C) Administration of trimethoprim-sulfamethoxazole D) Application of negative pressure wound therapy E) Debridement of the wound edges with wet-to-dry dressings

Answer 61

The correct response is Option A. There are incidents of surgical procedures of the breast associated with galactorrhea leading to skin breakdown, nipple necrosis, and cellulitis. A dopamine agonist such as bromocriptine will cause decreased lactation in cases of galactorrhea/galactocele, thereby improving wound healing. Antibiotics such as sulfamethoxazole and trimethoprim (Bactrim) are generally not required, because the exudate is sterile. There is no need for debridement of the wound edges. Negative pressure wound therapy may increase lactation and galactorrhea, further impairing wound healing. Metoclopramide is a dopamine antagonist used for nausea and vomiting.

Question 62

18-year-old woman comes to the office for evaluation of her breasts. Photographs of the patient are shown. Which of the following statements most accurately describes the anatomy of this patient's breasts? A) The areola is normal size although the breast is small B) The breast tissue is uniformly distributed throughout the breast pocket C) The inframammary fold is elevated D) The skin envelope has greater laxity than in a normal breast E) The underlying musculature is underdeveloped

Answer 62

The correct response is Option C. The tuberous breast deformity results in a protruding, oblong shape that resembles a tuberous root plant (Latin derivation tuber = to swell). The features noted in the tuberous breast deformity include a constricted breast base, decreased breast parenchyma, abnormal elevation of the inframammary fold, a decreased skin envelope, and herniation of the breast parenchyma through the central breast and into the areola. The areola is large and lacks firm underlying structure, thus allowing the breast tissue to protrude through this path of least resistance. The deformity is also often referred to as a tubular breast, constricted breast, doughnut breast, nipple breast, breast with narrow base, dome nipple, and snoopy dog breast. The overall etiologic factors leading to the full expression of the constricted breast deformity are still largely unknown and likely involve a delicate balance of anatomic and endocrinologic forces. A constricting fibrous ring at the level of the areola periphery, representing probably a thickening of the superficial fascia coupled with the normally absent fascial layer in the NAC, has been proposed as a likely cause. The ring is composed of dense fibrous tissue made of large concentrations of collagen and elastic fibers arranged longitudinally. It is usually denser at the lower part of the breast and does not allow the developing breast parenchyma to expand during puberty. It has been suggested that a thickening of the superficial fascia combined with the absence of a superficial fascial layer under the NAC is the underlying anatomic/histopathologic cause of the deformity. The cause of the thickened fascia is unknown, although at least one study by Klinger, Caviggioli, et al. demonstrated altered collagen in both disposition and quantity. The same study excluded amyloid deposition as a component of the fibrosis. The areola in the tuberous breast still contains the normal muscular structures that result in areolar changes with stimulation and temperature changes, although the tissue beneath the areola may be thinned.

Question 63

A 25-year-old woman comes to the office because she is dissatisfied after undergoing breast augmentation mammaplasty for correction of tuberous breast deformities. Physical examination shows two parallel creases running transversely across the lower pole of each breast with inferior displacement of the implant. Which of the following best describes the position of the original inframammary fold in this patient? A) Above the superior and inferior transverse creases B) At the inferior transverse crease C) At the superior transverse crease D) Below the superior and inferior transverse creases

Answer 63

The correct response is Option C. A double-bubble breast deformity following breast augmentation mammaplasty is represented by the development of two parallel, curvilinear transverse lines in the lower pole of the breast. The native inframammary fold is disrupted and represented by the superior transverse line. The lower transverse line represents the lower limit of implant pocket dissection or the final position of implant descent. Predisposing anatomic factors for the development of a double-bubble deformity include tuberous breasts, constricted inframammary folds, or a short inframammary fold-to-nipple distance. Other factors that can increase the risk for the development of a double-bubble deformity include glandular ptosis, postpartum involution of the breasts, excessive implant size, and overdissection of the implant pocket. Correction of the double-bubble deformity may require conversion of the implant to a subglandular position, capsulorrhaphies, use of form-stable implants, or dermal grafts.

Question 64

A 24-year-old nulliparous woman comes to the office for augmentation mammaplasty. She currently wears a size 34B brassiere and wants her brassiere size to be increased to a D cup. She is a good candidate for subglandular placement of implants. Which of the following risks is decreased by the use of the textured silicone shell compared with the smooth silicone shell? A) Capsular contracture B) Hematoma C) Prosthesis malposition D) Rippling E) Symmastia

Answer 64

The correct response is Option A. Texturing of the implant surface has been shown to decrease the rate of capsular contracture when compared with smooth implants when the implants are placed in the subglandular position. The benefit of textured implants may not be present when the implants are placed in a submuscular pocket. There is no difference in hematoma rates for textured versus smooth implants. Both symmastia and implant malposition are related to pocket dissection and not related to the type of implant placed. In the case of symmastia, the pockets have encroached upon the sternum and are close to each other or are touching. Implant malposition can be related to factors such as inadequate dissection of the pocket, or over-dissection of the pocket. Finally, some studies have demonstrated an increase in rippling with textured implant when compared with smooth implants. However, rippling may be more related to cohesiveness of the gel and fill volumes of the shell, because early reports of experience with the form-stable implant (Natrelle 410) seem to show decreased rates of rippling.

Question 65

A 49-year-old woman is evaluated because of a traumatic laceration of the right lower eyelid and cheek. Physical examination shows difficulty with eyelid closure, voluntary squinting, and animation. Which of the following branches of the facial nerve is most likely injured? A) Buccal B) Cervical C) Marginal mandibular D) Temporal E) Zygomatic

Answer 65

The correct response is Option E. Anatomically, the orbicularis oculi muscle is divided into three segments: pretarsal, preseptal, and orbital. However, functionally, the orbicularis oculi muscle is divided into the medial inner canthal orbicularis and the extracanthal orbicularis. The medial inner canthal orbicularis is responsible for blinking, lower lid tone, and the pumping mechanism of the lacrimal system. Innervation to the inner canthal orbicularis is from the buccal branches of the facial nerve. The zygomatic branch of the facial nerve innervates the extracanthal orbicularis, which controls eyelid closure, voluntary squinting, and animation. The temporal, marginal mandibular, and cervical branches do not provide innervation to the orbicularis oculi muscle.

Question 66

Which of the following is the most common complication associated with “donut” mastopexy? A) Boxy breast shape B) Increased distance from nipple to inframammary fold C) Loss of nipple sensation D) Nipple necrosis E) Widening of the areola

Answer 66

The correct response is Option E. A common complication of the “donut” (circumareolar) mastopexy is widening of the areola. This can be minimized by using a Gore-Tex suture placed using the “wagon-wheel” technique and limiting the amount of skin resected to a 2:1 ratio of outside diameter to areolar diameter. Boxy breast shape is associated with Wise pattern mastopexy. Nipple necrosis is associated with combined augmentation and mastopexy. Increased distance from the nipple to the inframammary fold is associated with vertical mastopexies in which the height of the medial and lateral pillars is too tall. Loss of nipple sensitivity is unusual because there is no parenchymal resection.

Question 67

A 27-year-old woman is evaluated because of pain 2 weeks after undergoing subglandular augmentation mammaplasty. She has no history of fever, chills, or drainage. Physical examination discloses a painful, tender cord in the inframammary region of the left breast. Which of the following is the most appropriate next step in management? A) Administration of an antibiotic B) Administration of an anticoagulant C) Administration of an anti-inflammatory agent D) Duplex ultrasonography E) Removal of the implant

Answer 67

The correct response is Option C. Mondor disease of the breast is a benign, self-limiting thrombophlebitis of the inframammary veins. Clinically, Mondor disease usually occurs 2 to 3 weeks postoperatively as a painful, tender cord within the superficial veins of the thoracoepigastric system. Management is observation and includes the use of warm, moist dressings and anti-inflammatory agents for symptomatic relief. The use of anticoagulation, antibiotics, or steroids is not indicated. Implant removal is not indicated in the absence of infection. Duplex ultrasonography is not required for management.

Question 68

A 65-year-old woman comes to the office 1 month before a scheduled mastopexy. Annual mammography shows a 1.5-cm mass in the upper outer quadrant. Core needle biopsy is performed. Pathologic examination of excised tissue identifies papilloma without atypia. Which of the following is the most appropriate next step in management? A) Bilateral breast sonography B) Excisional biopsy of needle-localized area C) Repeat annual mammography in 12 months D) Repeat mammography at 6-month intervals for 1 year E) Stereotactic vacuum-assisted biopsy

Answer 68

The correct response is Option B. Percutaneous biopsy methods are commonly accepted for the initial evaluation of clinically occult breast lesions, although certain nonmalignant lesions pose dilemmas with respect to the most appropriate clinical management. Papillary lesions of the breast can either be benign or malignant, although differentiation is radiologically difficult. Moreover, it is difficult for pathologists to reliably distinguish among benign, atypical, and malignant papillary lesions on the limited fragmented tissue specimens they receive after needle sampling. Previous studies have demonstrated high rates of ductal carcinoma in situ (11%) in patients diagnosed with benign papillomas by needle biopsy and who subsequently underwent a surgical excision, although conflicting data suggest an extremely decreased rate of malignancy when histology is benign on needle biopsy. The management of benign papillary lesions is somewhat controversial. Although conservative follow-up with either yearly mammogram or short-interval follow-up may be appropriate for certain patients diagnosed with benign papilloma, certain features of this patient’s lesion make conservative follow-up inappropriate. Sonographic follow-up in a 65-year-old woman with mature breast parenchyma and a solid mammographically detected mass would not provide much additional information, and a repeat percutaneous biopsy, whether core needle or vacuum-assisted, would also not be effective. Given the size of the lesion and the age of the patient, surgical excision is warranted despite the lack of atypia on needle biopsy. Benign papillomas tend to be smaller than 1 cm and centrally located, whereas malignant lesions are more often greater than 1.5 cm and are peripherally located.

Question 69

A 28-year-old woman desires augmentation mammaplasty with silicone implants. Physical examination shows tuberous breast deformity with an elevated inframammary crease. Sternal notch to nipple distance is 21 cm bilaterally. Nipple to inframammary crease distance is 3.5 cm bilaterally. Periareolar mastopexy with 350-mL silicone implants is planned. Which of the following operative plans will most effectively minimize the likelihood of a double-bubble deformity? A) Lower the inframammary crease by 3 cm B) Perform radial release of the lower pole breast fascia C) Place implants in subparenchymal pocket D) Reinforce the inframammary crease with acellular dermal matrix E) Use highly cohesive gel implants

Answer 69

The correct response is Option B. The tuberous breast is a developmental deformity characterized by a constricted inframammary fold, short nipple to inframammary crease distance, and both horizontal and vertical deficiencies. The pathophysiology of the tuberous breast predisposes the patient to develop a double-bubble deformity. In this patient, the inframammary crease must be lowered to accommodate the implant and improve the vertical skin deficiency. Radial release of the lower pole breast fascia is done with either a cautery or a knife. Multiple radial incisions are made, thereby allowing the tight crease to expand and decrease the chance for a double-bubble deformity. Lowering the crease is necessary but will increase the chances of a double-bubble deformity. Subparenchymal implant placement and use of highly cohesive gel implants may help but are not the essential procedures required. The use of acellular dermal matrix can help secure the position of the inframammary crease in a patient who develops a double-bubble deformity secondary to an inferior migration of the implant below the inframammary crease. This does not apply in the patient described.

Question 70

A 37-year-old woman comes to the clinic to be evaluated for augmentation mammaplasty to improve her breast shape. She is gravida 3, para 3, and breast-fed all of her children. On examination, she has decreased superior pole volume, and the distance from nipple to sternal notch is 28 cm. The nipple-areola complex is below the inframammary fold by 4 cm and is at the lower contour of the breast. Which of the following Regnault classifications of ptosis best describes these findings? A) Grade I B) Grade II C) Grade III D) Pseudoptosis

Answer 70

The correct response is Option C. The Regnault classification of breast ptosis is based on the relationship of the nipple to the inframammary fold (IMF) and to the lower contour of the gland. Pseudoptosis is the not true ptosis. In this situation, the nipple is above the level of the IMF but the breast parenchyma has descended below the IMF. Grade I is minor ptosis with the nipple at the level of the IMF and above the lower contour of the gland. Grade II is moderate ptosis with the nipple below the level of the IMF and above the lower contour of the gland. Grade III is major ptosis with the nipple below the level of the IMF and at the lower contour of the gland.

Question 71

A French woman, who underwent placement of Poly Implant Prothèse (PIP) gel implants in 2009, comes to the office for consultation because she had heard that the implants were filled with a nonmedical grade silicone. She reports that she has not had any problems with the implants, but would like to know the implications of retaining the implants and whether she should have them removed. This patient should be told that she is at increased risk for which of the following complications if she retains the implants? A) Breast cancer B) Cytotoxicity C) Heavy metal poisoning D) Implant rupture E) Siloxane poisoning

Answer 71

The correct response is Option D. The final report, in conjunction with the Department of Health in Australia, has shown a 2 to 6 times increased rupture rate in Poly Implant Prothèse (PIP) implants, which is detectable within 5 years of implantation. Increased levels of siloxane have been detected, but are not considered a health risk. No organic impurities have been detected and platinum levels are decreased in PIP gel compared with medical grade silicone. There is no increased breast cancer risk and no evidence of cytotoxicity. In the light of the increased rupture rate and the nonmedical grade nature of PIP silicone gel, the following recommendations were made: all providers of breast implant surgery should contact any women who have or may have PIP implants, if they have not already done so, and offer them a specialist consultation and any appropriate investigation to determine if the implants are still intact; if the original provider is unable or unwilling to do this, a woman should seek referral through her general practitioner to an appropriate specialist; if there is any sign of rupture, she should be offered an explantation; if the implants still appear to be intact, she should be offered the opportunity to discuss with her specialist the best way forward; if, in the light of this advice a woman decides with her specialist that, in her individual circumstances, she wishes to have her implants removed, her health care provider should support her in carrying out this surgery. Where her original provider is unable or unwilling to help, the NHS will remove, but not normally replace, the implants; if a woman decides not to seek early explantation, she should be offered annual follow up in line with the advice issued by the specialty surgical associations in January 2012. Women who make this choice should be encouraged to consult their doctor if they notice any signs of tenderness or pain, or swollen lymph glands in or around their breasts or armpits, which may indicate a rupture. At the first signs of rupture, they should be offered removal of the implants.

Question 72

A 35-year-old woman comes to the office for consultation because she is dissatisfied with the appearance of her “deflated” and “saggy” breasts. Augmentation/mastopexy is planned. Compared with placement of the implant in the subglandular position, placement of the implant in the subpectoral space will preserve blood supply to the breast tissue and skin through which of the following arteries? A) Internal thoracic B) Lateral thoracic C) Superficial superior epigastric D) Thoracoacromial E) Thoracodorsal

Answer 72

The correct response is Option D. The perfusion of the nipple-areola complex is a major concern during breast procedures involving periareolar and intraparenchymal incisions. The nipple-areola complex has a very rich and overlapping perfusion through multiple sources. This fact allows the design of various pedicles to carry the nipple and areola with different techniques. The blood supply through the internal thoracic vessels reaches the breast, nipple, and areola through the intercostal perforators, which may be divided during both subpectoral and subglandular implant placement. The location of the implant deep or superficial to the pectoralis muscle will not change the perfusion through the superficial epigastric vessels. The same is true for the blood supply through the lateral thoracic vessels. However, the flow through the thoracoacromial vessels to the breast parenchyma will be preserved by placement of the implant deep to the pectoralis muscle. Creation of a subglandular pocket above the muscle will interrupt the collaterals from the thoracoacromial vessels through the muscle to the parenchyma. The thoracodorsal artery is not a major source of blood supply to the breast and the position of the implant will not affect it.

Question 73

A 32-year-old woman is scheduled to undergo augmentation mammaplasty with highly cohesive, anatomically shaped, silicone-filled breast implants. She asks the surgeon about postoperative monitoring for implant rupture. This patient should be counseled that, according to FDA recommendations, postoperative monitoring for rupture most appropriately includes which of the following? A) Manual examination 3 years postoperatively, then annually thereafter B) MRI screening 2 years postoperatively, then every 3 years thereafter C) MRI screening 3 years postoperatively, then every 2 years thereafter D) Ultrasonography screening 2 years postoperatively, then every 3 years thereafter E) Ultrasonography screening 3 years postoperatively, then every 2 years thereafter

Answer 73

The correct response is Option C. Diagnosis of rupture is difficult by physical examination alone, which is why the majority of ruptures are silent. Subsequent MRI screening for silent rupture is recommended initially 3 years postoperatively, then every 2 years thereafter. Highly cohesive, anatomically shaped, silicone-filled breast implants combine the “gummy bear” silicone with an anatomical shape, in which inferior pole projection is higher than the superior pole projection. In studies of Allergan’s Natrelle 410 breast implants (the “Pivotal Study,” the 410 Swedish MRI study, and the 410 European MRI study) approximately 3 in 100 women had silent ruptures. Cohesive gel is still subject to rupture, because rupture occurs when the shell fails. In cohesive implants, however, as opposed to noncohesive implants, the rupture rarely becomes extracapsular.

Question 74

A 45-year-old woman comes to the office 10 years after undergoing subglandular implantation of textured silicone implants for augmentation mammaplasty. Physical examination shows swelling of the left breast. She is concerned about cancer. Increased incidence of which of the following malignancies is associated with breast implants? A) Acute myeloid leukemia B) Anaplastic large cell lymphoma C) Angiosarcoma D) Infiltrating ductal carcinoma E) Malignant fibrous histiocytoma

Answer 74

The correct response is Option B. Several reports have suggested an association between breast implants and anaplastic large cell lymphoma (ALCL), which is an extremely rare malignancy. In these cases, ALCL has usually occurred several years after implantation as swelling or a mass around the implant and is often associated with a periprosthetic seroma. Treatments have included capsulectomy with implant removal and chemotherapy and/or radiation therapy, though there is no defined consensus regimen. Despite evidence of an increased risk of ALCL in breast implant patients, the absolute risk remains extremely low. Several large epidemiologic studies have demonstrated a similar or lower incidence of breast cancer (infiltrating ductal carcinoma) among patients who have undergone prosthetic augmentation mammaplasty surgery compared with those who have not. Most cases of ALCL have been in textured implants. Angiosarcoma and malignant fibrous histiocytoma are two sarcomas that may arise in the breast. Angiosarcoma may be caused by radiation therapy for breast cancer. Neither of these sarcomas has been associated with breast implants. Acute myeloid leukemia may be associated with radiation treatment to the breast but has not been associated with breast implants.

Question 75

A 33-year-old woman with no family history of breast cancer undergoes bilateral augmentation mammaplasty with 300 mL of autologous fat per breast. Six months later, she has onset of pain in the right breast. Mammography shows linear clustered microcalcifications in the lower inner quadrant of the right breast, small lipid cysts bilaterally with scattered dystrophic rod-like calcifications in the upper outer quadrants bilaterally, and heterogeneity of the pectoral muscles. Which of the following is the most appropriate next step in management? A) Baseline mammography between ages 35 and 40 and yearly thereafter B) Core needle biopsy of the bilateral upper outer quadrants C) Core needle biopsy of the right lower inner quadrant D) Repeat mammography at 6 months and 12 months E) Repeat mammography in 1 year

Answer 75

The correct response is Option C. Augmentation mammaplasty with autologous fat transfer has become an increasingly popular option for patients desiring modest volumetric improvement. Despite its popularity, there is still some concern regarding its safety and efficacy. ASPS offered guidelines on fat grafting for reconstructive procedures of the breast in 2009. However, caution is recommended in the setting of cosmetic procedures because the impact on radiologic changes in follow-up is still uncertain to date. Fat necrosis is a nonspecific histologic finding most commonly resulting from surgery, trauma, or radiation therapy. It is common after fat transfer procedures, though often is clinically occult, and detected through follow-up mammography. The mammographic images of fat necrosis range from lipid cysts to findings that are suspected for malignancy such as clustered microcalcifications or spiculated masses. The most frequent mammographic finding in the breast parenchyma after augmentation mammaplasty with fat transfer is bilateral scattered microcalcifications followed by radiolucent oil cysts with or without microcalcification. Microcalcifications represent an evolution in the mammographic appearance of fat necrosis and are usually not present in early postoperative screening, but rather are a relatively late finding that is present months to years after the inciting trauma. It is imperative that radiologists distinguish between benign and suspected microcalcifications in order to minimize the number of postoperative biopsies and frequent follow-up imaging. Although round, spherical, punctuate, and diffusely scattered calcifications are typical of benign processes, cluster, branching microcalcifications can be indicative of a malignant process and should be worked up. For this 33-year-old patient with no baseline mammography and a suspected lesion within 6 months of the procedure, routine or short-interval mammographic screening is not appropriate. A biopsy of the suspected area is required, and this patient should undergo a core needle biopsy of the clustered microcalcifications of the right breast, while the more benign-appearing calcifications within the upper outer quadrants can be observed.

Question 76

A 35-year-old woman with tuberous breast deformity is scheduled to undergo augmentation/mastopexy. A smooth, round, cohesive gel implant will be used. This patient is at higher risk for which of the following complications when compared with augmentation/mastopexy performed on a patient without a tuberous breast? A) Capsule contracture B) Double bubble C) Hematoma D) Nipple-areola depigmentation E) Rippling

Answer 76

The correct response is Option B. The classic features of a tuberous breast deformity include a constricted base with a high inframammary crease and herniation of breast parenchyma into the nipple-areola complex producing a large-diameter areola. Variable extent of micromastia is associated as well as breast asymmetry. When a patient has a high and tight inframammary crease, this crease must be released to accommodate an implant and allow correction of the deformity. If this native crease does not fully expand, then a double bubble will occur. Over time, the lower pole skin stretches in response to the implant and this double bubble often improves spontaneously. The incidence of capsule contracture, hematoma, nipple-areola depigmentation, and rippling should be similar to a patient who undergoes periareolar augmentation/mastopexy without a tuberous breast.

Question 77

A 28-year-old woman is scheduled to undergo vertical mastopexy. She has no history of previous breast surgery. A superior pedicle technique is planned. Which of the following is the dominant blood supply for this pedicle? A) Deep branches of the internal mammary artery from the fourth interspace B) Deep branches of the internal mammary artery from the fifth interspace C) Superficial branches of the internal mammary artery from the second interspace D) Superficial branches of the internal mammary artery from the fourth interspace E) Superficial branches of the lateral thoracic artery

Answer 77

The correct response is Option C. The breast receives its arterial blood supply from multiple sources, and this fact is used to design multiple pedicles for the nipple-areola complex that can work reliably for both mastopexy and reduction mammaplasty procedures. The superior pedicle receives its arterial blood supply primarily from the internal mammary branch from the second interspace. It is usually about 1 to 2 cm below the surface of the skin just medial to the breast meridian as it approaches the areola and may be localized with a handheld Doppler device during preoperative planning. The inferior pedicle and central pedicle designs are primarily supplied by branches of the internal mammary system from the fourth interspace. Additionally, there is some accessory input from the intercostal branches at the level of the inframammary fold with the inferior pedicle design. These secondary vessels are typically interrupted in a central pedicle operation. The medial pedicle design receives its arterial input mainly from the third superficial branch of the internal mammary artery. This vessel may be damaged by previous augmentation mammaplasty. The lateral pedicle design receives its arterial supply from superficial branches of the lateral thoracic artery.

Question 78

A 33-year-old woman with no family history of breast cancer undergoes bilateral augmentation mammaplasty with 300 mL of autologous fat per breast. Six months later, she has onset of pain in the right breast. Mammography shows linear clustered microcalcifications in the lower inner quadrant of the right breast, small lipid cysts bilaterally with scattered dystrophic rod-like calcifications in the upper outer quadrants bilaterally, and heterogeneity of the pectoral muscles. Which of the following is the most appropriate next step in management? A) Baseline mammography between ages 35 and 40 and yearly thereafter B) Core needle biopsy of the bilateral upper outer quadrants C) Core needle biopsy of the right lower inner quadrant D) Repeat mammography at 6 months and 12 months E) Repeat mammography in 1 year

Answer 78

The correct response is Option C. Augmentation mammaplasty with autologous fat transfer has become an increasingly popular option for patients desiring modest volumetric improvement. Despite its popularity, there is still some concern regarding its safety and efficacy. ASPS offered guidelines on fat grafting for reconstructive procedures of the breast in 2009. However, caution is recommended in the setting of cosmetic procedures because the impact on radiologic changes in follow-up is still uncertain to date. Fat necrosis is a nonspecific histologic finding most commonly resulting from surgery, trauma, or radiation therapy. It is common after fat transfer procedures, though often is clinically occult, and detected through follow-up mammography. The mammographic images of fat necrosis range from lipid cysts to findings that are suspected for malignancy such as clustered microcalcifications or spiculated masses. The most frequent mammographic finding in the breast parenchyma after augmentation mammaplasty with fat transfer is bilateral scattered microcalcifications followed by radiolucent oil cysts with or without microcalcification. Microcalcifications represent an evolution in the mammographic appearance of fat necrosis and are usually not present in early postoperative screening, but rather are a relatively late finding that is present months to years after the inciting trauma. It is imperative that radiologists distinguish between benign and suspected microcalcifications in order to minimize the number of postoperative biopsies and frequent follow-up imaging. Although round, spherical, punctuate, and diffusely scattered calcifications are typical of benign processes, cluster, branching microcalcifications can be indicative of a malignant process and should be worked up. For this 33-year-old patient with no baseline mammography and a suspected lesion within 6 months of the procedure, routine or short-interval mammographic screening is not appropriate. A biopsy of the suspected area is required, and this patient should undergo a core needle biopsy of the clustered microcalcifications of the right breast, while the more benign-appearing calcifications within the upper outer quadrants can be observed.

Question 79

A 35-year-old woman with tuberous breast deformity is scheduled to undergo augmentation/mastopexy. A smooth, round, cohesive gel implant will be used. This patient is at higher risk for which of the following complications when compared with augmentation/mastopexy performed on a patient without a tuberous breast? A) Capsule contracture B) Double bubble C) Hematoma D) Nipple-areola depigmentation E) Rippling

Answer 79

The correct response is Option B. The classic features of a tuberous breast deformity include a constricted base with a high inframammary crease and herniation of breast parenchyma into the nipple-areola complex producing a large-diameter areola. Variable extent of micromastia is associated as well as breast asymmetry. When a patient has a high and tight inframammary crease, this crease must be released to accommodate an implant and allow correction of the deformity. If this native crease does not fully expand, then a double bubble will occur. Over time, the lower pole skin stretches in response to the implant and this double bubble often improves spontaneously. The incidence of capsule contracture, hematoma, nipple-areola depigmentation, and rippling should be similar to a patient who undergoes periareolar augmentation/mastopexy without a tuberous breast.

Question 80

A 28-year-old woman is scheduled to undergo vertical mastopexy. She has no history of previous breast surgery. A superior pedicle technique is planned. Which of the following is the dominant blood supply for this pedicle? A) Deep branches of the internal mammary artery from the fourth interspace B) Deep branches of the internal mammary artery from the fifth interspace C) Superficial branches of the internal mammary artery from the second interspace D) Superficial branches of the internal mammary artery from the fourth interspace E) Superficial branches of the lateral thoracic artery

Answer 80

The correct response is Option C. The breast receives its arterial blood supply from multiple sources, and this fact is used to design multiple pedicles for the nipple-areola complex that can work reliably for both mastopexy and reduction mammaplasty procedures. The superior pedicle receives its arterial blood supply primarily from the internal mammary branch from the second interspace. It is usually about 1 to 2 cm below the surface of the skin just medial to the breast meridian as it approaches the areola and may be localized with a handheld Doppler device during preoperative planning. The inferior pedicle and central pedicle designs are primarily supplied by branches of the internal mammary system from the fourth interspace. Additionally, there is some accessory input from the intercostal branches at the level of the inframammary fold with the inferior pedicle design. These secondary vessels are typically interrupted in a central pedicle operation. The medial pedicle design receives its arterial input mainly from the third superficial branch of the internal mammary artery. This vessel may be damaged by previous augmentation mammaplasty. The lateral pedicle design receives its arterial supply from superficial branches of the lateral thoracic artery.

Question 81

An otherwise healthy 40-year-old woman comes to the office for augmentation mammaplasty. Mammography 6 months ago showed no abnormalities. Family history is negative for breast cancer. She wants to know if silicone gel implants are safe and what she should do after the procedure to monitor the implant for evidence of rupture. According to the current federal guidelines, which of the following is the most appropriate recommendation to this patient regarding surveillance? A) MRI 3 years after implantation and every 2 years thereafter B) MRI every 10 years C) MRI if symptoms such as chronic myalgia and fatigue develop D) Yearly mammograms E) Yearly MRI

Answer 81

The correct response is Option A. Evidence-based data to confirm the validity of screening patients with silicone implants are lacking. In 2011, the FDA issued recommendations for physicians on the use of silicone gel-filled implants. Recommendations included providing copies of educational brochures, giving appropriate informed consent, maintaining medical vigilance, and reporting adverse events. It also suggested that patients undergoing augmentation mammaplasty get an MRI 3 years after implant placement and every 2 years thereafter. The purpose of these recommendations is not to replace routine cancer surveillance.

Question 82

A 30-year-old woman comes to the office for augmentation mammaplasty and mastopexy after a 50-lb (23-kg) weight loss. She wears a size 38B brassiere. Physical examination shows grade II ptosis and a sternal notch to nipple distance of 26 cm bilaterally. Simultaneous augmentation mammaplasty with short-T mastopexy using smooth saline-filled breast implants that will be implanted in a dual-plane configuration through an inframammary incision is planned. Which of the following factors puts this patient at highest risk for reoperation? A) Inframammary implant insertion route B) Presence of breast ptosis C) Use of drains D) Use of saline implants E) Use of smooth-walled implants

Answer 82

The correct response is Option B. It has long been realized that combination augmentation mammaplasty operations are more difficult and have a higher revision rate than either operation alone. A recent review of 177 primary augmentation mammaplasty cases found that, of the factors listed, preexisting breast ptosis and simultaneous mastopexy were both linked to a higher rate of reoperation when possible contributing factors were statistically analyzed. Furthermore, increasing grades of breast ptosis were linked with increasingly higher reoperation rates. Although incision site for augmentation mammaplasty has been markedly linked to the rates of capsular contracture, inframammary incisions have been shown in at least two studies to date to have the lowest rate of capsule formation, with periareolar and transaxillary incisions showing 5 to 10 times higher rates of capsule-related complications.

Question 83

A 30-year-old woman comes to the office because of a 3-week history of unilateral swelling of the left breast. She underwent subglandular placement of textured silicone breast implants 4 years ago. She has had no trauma, fevers, or chills. A 1-week course of an oral antibiotic prescribed by her family physician has failed to resolve the swelling. On physical examination, the left breast is 300 to 400 mL larger than the right breast. No other abnormalities are noted. Ultrasonography report shows seroma and results are negative for hematoma or mass. Which of the following is the most likely diagnosis in this patient? A) Anaplastic large cell lymphoma B) Double capsule phenomenon C) Giant fibroadenoma of the breast D) Hematoma due to capsule tear E) Periprosthetic abscess

Answer 83

The correct response is Option B. The combination of late-onset swelling without signs of periprosthetic infection (fever, cellulitis), no history of trauma, and a negative ultrasonography suggests late-onset seroma, as can occur with a double capsule phenomenon. Late seromas occur as a complication in about 1% of reported breast implant series. This issue seems to be more common in the setting of textured implants, particularly those implants manufactured with an aggressive texturing process. At surgery, a capsule layer is seen lining the pocket, which often contains a substantial volume of serosangineous seroma fluid and a textured implant coated in a tight second capsule at the center of the pocket. Double capsule has been reported in both the subglandular and submuscular positions. A giant fibroadenoma of the breast would have a dominant mass, distortion of the breast shape, and would be visible on ultrasonography. Abscess would be likely to occur with fever, chills, and cellulitis of the breast. Hematoma of this size would be likely to have a history of trauma, breast pain, and external bruising. Although anaplastic large cell lymphoma is a possibility in the differential of late-onset seromas, it is a rare disorder. Seroma fluid, obtained either by ultrasound-guided aspiration or at the time of open surgery, should be sent for cytologic examination and immunohistochemistry to rule out this rare possibility.

Question 84

A 53-year-old woman comes to the office for evaluation of breast asymmetry. Reduction of the left breast and augmentation of the right breast with implant and autologous fat transfer are planned. She is concerned about fat injection and cancer risk. Which of the following is the most appropriate response regarding mammographic changes after fat transfer? A) Calcifications warranting biopsy are more likely on the fat transfer side B) Calcifications warranting biopsy are more likely on the reduction side C) Masses requiring biopsy are more likely on the reduction side D) Scarring will be decreased on the reduction side E) There are no differences between mammographic findings in fat transfer and reduction

Answer 84

The correct response is Option C. Fat transfer to the breast remains a controversial procedure. There are some concerns about the oncologic safety of fat transfer, and for this reason some authors do not recommend fat transfer in patients with a history of cancer. Another concern about fat transfer is the potential difficulty in screening for malignancy. Rubin, et al. compared mammographic changes after fat transfer with changes after reduction mammaplasty. In this blinded study, radiologists reviewed pre- and postoperative mammograms of patients who had undergone augmentation and fat transfer and reduction mammaplasty. In the reduction cohort, masses requiring biopsy and scarring were more common; other abnormalities, including oil cysts, benign calcifications, and calcifications requiring biopsy showed no differences between the groups.

Question 85

A 53-year-old woman comes to the office because of unilateral swelling of the breast 5 years after undergoing subglandular augmentation mammaplasty. A diagnosis of anaplastic large T-cell lymphoma (ALCL) is established. Which of the following is most likely to represent the progression of this patient's disease when compared with a patient who has ALCL but no breast prostheses? A) A more aggressive clinical course and a poorer prognosis B) A more aggressive clinical course but a more favorable prognosis C) A more indolent clinical course and a more favorable prognosis D) A more indolent clinical course but a poorer prognosis E) The same clinical course and prognosis

Answer 85

The correct response is Option C. Anaplastic large T-cell lymphoma (ALCL) is a rare (1 per million) non-Hodgkin lymphoma that has been reported in women with and without breast prostheses. However, increasing case reports suggest an association with breast prostheses, although direct causation has not been established. ALCL associated with breast prostheses has malignant cells infiltrating the periprosthetic capsule or in the periprosthetic fluid collection. It is associated with both silicone- and saline-filled prostheses and seen in patients who have had prostheses for augmentation mammaplasty as well as breast reconstruction. Although the cytology is the same between ALCL associated with and without breast prostheses, ALCL that develops around prostheses tend to have an indolent clinical course and favorable prognosis when compared with systemic ALCL.

Question 86

A 49-year-old woman is scheduled to undergo subglandular augmentation mammaplasty with silicone prostheses. During the preoperative discussion, the patient asks about postoperative complications with silicone versus saline prostheses. Which of the following is a disadvantage of using silicone in this patient? A) Their rupture results in an obvious decrease in breast size B) They are more likely to result in invasive breast cancer C) They can obscure breast tissue on mammagraphy D) They may show more rippling

Answer 86

The correct response is Option C. Silicone prostheses are radiopaque on mammography. Therefore, when placed in the subglandular position, a small percentage of breast tissue is obscured on mammography. Breast prostheses made completely of or in part with silicone have not been shown to cause a delay in detection of breast cancer. Women with breast prostheses are not more likely to develop breast cancer. Women with breast prostheses who have developed breast cancer are not diagnosed at a more advanced stage and do not have a worse prognosis or survival when compared with women without prostheses. Silicone prostheses are less likely to show superior pole rippling when compared with saline prostheses. If a saline prosthesis ruptures, the saline tends to become absorbed by the body, resulting in an obvious decrease in breast size after a few days. When silicone prostheses rupture, the silicone may remain intracapsular. These ruptures may change the breast shape slightly but usually do not change the size and are often subclinical.

Question 87

A 33-year-old woman comes to the office for consultation because she is dissatisfied with the "sagging" appearance of her breasts. Examination shows grade II ptosis and loss of fullness in the upper pole. A vertical mastopexy is planned. The most common medial innervation to the nipple-areola complex is the anterior cutaneous branches of which of the following intercostal nerves? A) Second and third B) Third and fourth C) Fourth and fifth D) Fifth and sixth E) Sixth and seventh

Answer 87

The correct response is Option B. The most common medial innervation of the nipple-areola complex is mainly 57% from the anterior cutaneous branches of the third and fourth intercostal nerves. The third intercostal nerve accounts for 21.4%. They always reach the areolar edge between 8 and 11 o’clock on the left and 1 and 4 o’clock on the right. The nerve innervation to the nipple-areola complex is important in planning different incisions around the areola in both reduction mammaplasty and mastopexy.

Question 88

A 25-year-old woman is considering augmentation mammaplasty with silicone prostheses. The patient asks about the associated risks of developing connective tissue disease. Which of the following risk assessments is most accurate in this patient? A)Increased risk of extracapsular leak only B)Increased risk of intra- and extracapsular leak C)Increased risk only if the silicone migrates to the lymph node D)Increased risk only in the pre-1990 prostheses E)No increased risk

Answer 88

The correct response is Option E. Concern regarding an association between silicone breast prostheses and connective tissue disease was raised in the 1980s and early 1990s, eventually leading to the US Food and Drug Administration (FDA) moratorium of the use of silicone breast prostheses in augmentation mammaplasty. Since then, multiple cohort studies and case control studies in Europe and North America have failed to determine a causative association between silicone breast prostheses and any traditional or atypical connective tissue diseases.

Question 89

A 23-year-old woman comes to the office for consultation regarding surgical correction of a tuberous breast deformity. On physical examination, which of the following characteristics is most likely in this patient? A) Absence of the sternal head of the pectoralis muscle B) Effacement of the inframammary fold C) Grade III ptosis of the nipple-areola complex D) Herniation of breast tissue into the nipple-areola complex E) Macromastia

Answer 89

The correct response is Option D. Physical examination of a tuberous breast would show herniation of the nipple-areola complex. A constricted inframammary fold, rather than an effaced inframammary fold, is often associated with tuberous breast deformity. Macromastia and/or grade III ptosis of the nipple-areola complex are not standard components of tuberous breast deformity. Absence of the sternal head of the pectoralis muscle is a characteristic feature of Poland syndrome.

Question 90

A 24-year-old woman with bilateral micromastia comes for consultation regarding augmentation mammaplasty. The patient says she would like her breasts to be "as big as possible." On examination, which of the following is the most important factor in determining the maximum acceptable prosthesis size for this patient? A) Breast base width B) Diameter of the areola C) Grade of nipple-areola ptosis D) Maximum manufactured prosthesis volume E) Pectoralis muscle height-to-prosthesis height ratio

Answer 90

The correct response is Option A. The most important factor in determining the maximum acceptable prosthesis size in this patient is breast base width. Grade of nipple-areola ptosis, areola diameter, maximum manufactured prosthesis volume, and pectoralis height may all impact overall appearance of the breast but do not have an impact on breast prosthesis size choice.

Question 91

A 50-year-old woman comes to the office for consultation about improving the appearance of her "saggy" breasts. She has lost 100 lb (45 kg) during the past 18 months by diet. Photographs are shown. Physical examination shows breast deflation and marked ptosis. A Wise pattern mastopexy with augmentation mammaplasty is planned. Which of the following arteries is most likely to provide circulation to the breast gland and nipple during submuscular augmentation in this patient? A)Intercostal B)Pectoral C)Superior epigastric D)Thoracoacromial E)Thoracodorsal

Answer 91

The correct response is Option D. The thoracoacromial artery and vein travel just deep to the pectoralis major muscle, supplying circulation to the overlying breast tissue and skin. Subglandular augmentation mammaplasty disrupts the connection between the thoracoacromial vessels and the overlying breast. This leads to a higher risk of wound-healing complications when placing the prosthesis in the subglandular plane. The submuscular plane of dissection maintains the connection between the thoracoacromial vessel and overlying breast and skin, allowing better potential healing. Intercostal arteries are multiple and are not completely disconnected with either subglandular or subpectoral augmentation mammaplasty. The superior epigastric artery provides circulation to the rectus abdominis muscle and abdomen. This artery would be injured with the mastopexy procedure. The thoracodorsal artery supplies the latissimus dorsi muscle and not the chest.

Question 92

A 35-year-old woman comes to the office with her boyfriend for consultation regarding augmentation mammaplasty. She currently wears a size 34B brassiere and is considering having her brassiere size increased to a D cup. She says she is happy with the way she looks in clothes, but the boyfriend indicates he would like to see a little more cleavage when she is in a swimsuit. History includes liposuction of her lateral thighs 6 months ago by a local dermatologist; she was satisfied with the result. She has also had injection of botulinum toxin type A to the glabella 3 times in the last year. Which of the following is the best reason to refuse performing the procedure for this patient? A) The patient may be being pushed into surgery B) The patient may be a “surgiholic” C) The patient may have body dysmorphic disorder D) The patient may have a personality disorder E) The patient may have unrealistic expectations

Answer 92

The correct response is Option A. Most aesthetic surgeons and mental health professionals agree that patients who exhibit even mild signs of psychiatric problems are not good candidates for aesthetic surgery. Many patients present without obvious signs of problems and are unfortunately discovered when postoperative problems arise. However, there are certain groups of patients with easily identifiable characteristics that constitute a red flag: those who are pushed into surgery by others, those with whom you are incompatible, the ?surgiholic? with a long past surgical history, those facing marital or familial disapproval, those with body dysmorphic disorder, the overly demanding patient, and those with unrealistic expectations.

Question 93

A 25-year-old woman comes to the office because of a 1-week history of erythema and clear drainage from the right breast 6 weeks after undergoing bilateral augmentation mammaplasty. She is afebrile and her vital signs are within normal limits. The drainage from the breast is sent for cultures. Broad-spectrum antibiotics are administered, but no improvement is noted over the next 48 hours. Surgical debridement and explantation of the prostheses are performed. After 7 days, cultures grow Mycobacterium fortuitum. Which of the following is the most appropriate next step? A) Administration of ciprofloxacin and trimethoprim-sulfamethoxazole for 6 weeks B) Administration of ciprofloxacin and trimethoprim-sulfamethoxazole for 6 months C) Administration of isoniazid, rifampicin, and pyrazinamide for 6 weeks D) Administration of isoniazid, rifampicin, and pyrazinamide for 6 months E) No antibiotic therapy is needed because the infected prostheses have been removed

Answer 93

The correct response is Option B. The most appropriate next step in management is to initiate a 6-month course of ciprofloxacin and trimethoprim-sulfamethoxazole (Bactrim). Mycobacterium fortuitum is an atypical, nontuberculous mycobacterium (NTM), and it is one of the most common causes of NTM soft-tissue infections. It occurs most commonly in the presence of foreign bodies, such as breast prostheses. The incidence of these opportunistic infections has increased over the years. NTM infections can be more indolent and manifest weeks, or even months, following surgery. They occur most commonly with erythema, swelling, and clear drainage, although purulence may be seen. Fever may be absent. On surgical exploration, exuberant granulation tissue and turbid, odorless fluid are often noted. Routine Gram stains and cultures are usually negative. Therefore, it is imperative to request acid-fast bacilli staining and mycobacterial cultures if suspicion of NTM infection is high. Removal of the prosthesis and thorough debridement of the periprosthetic space, followed by long-term (3 to 6 months) antibiotic therapy, is required to treat this infection. Culture sensitivities should guide the antibiotic regimen, but ciprofloxacin, trimethoprim-sulfamethoxazole (Bactrim), clarithromycin, and doxycycline are used commonly for treatment. Reimplantation of the prosthesis should not be considered for a period of at least 6 months. Isoniazid, rifampicin, and pyrazinamide are standard antibiotics used to treat tuberculosis caused by Mycobacterium tuberculosis, not atypical mycobacteria. Although removal of the affected prosthesis is required, long-term antibiotic therapy is an essential part of the treatment.

Question 94

A 43-year-old woman comes to the office for consultation regarding augmentation mammaplasty. She has never had any lumps or nipple discharge from her breasts, and has no family history of breast cancer. After discussion, she chooses saline prostheses. She is concerned about breast cancer and inquires about screening. Which of the following screening studies is most appropriate for this patient after augmentation? A) CT scan B) Mammography C) MRI D) Positron emission tomography E) Ultrasonography

Answer 94

The correct response is Option B. Current recommendations for breast cancer screening in women with augmentation mammaplasty include mammography with Eklund views. In the Eklund technique, the prosthesis is pushed back against the chest wall, and the breast tissue is pulled forward and around the prosthesis. The use of this technique increases the sensitivity of mammography for breast cancer. Breast prostheses may affect the visualization of breast tissue, and it has been suggested that diagnostic mammography be obtained instead of screening mammography, even for the asymptomatic patient. CT scanning has been studied for the evaluation of the breast but is not routinely used as a tool for breast imaging. MRI is recommended for the evaluation of a ruptured silicone prosthesis. The technique has high sensitivity, but lower specificity and high cost. It is not recommended as a screening tool for breast cancer in the general population at this time, but it may play a role in the high-risk patient. Positron emission tomography is not used as a screening test for breast cancer. It is often used as an adjunct in patients diagnosed with breast cancer to determine if the cancer has spread to the lymph nodes or other parts of the body. Ultrasonography may be used for screening but is not recommended because it is very operator dependent. It will often be used as an adjunct to mammography in screening or if a suspected lesion is found.

Question 95

A 35-year-old woman comes for consultation regarding breast prosthesis removal because she is concerned about her risk of cancer. Specifically, she has read about anaplastic large cell lymphoma in women with breast prostheses. She underwent augmentation mammaplasty with saline breast prostheses 5 years ago. Physical examination shows absence of contracture and satisfactory position. Which of the following is the most appropriate next step in management? A) Complete blood cell count B) Evaluation by a hematologist C) MRI of the breasts D) Prosthesis removal E) Reassurance

Answer 95

The correct response is Option E. The US Food and Drug Administration (FDA) searched its adverse event reporting systems for reports received between January 1, 1995 and December 1, 2010, including information submitted by manufacturers as part of their required post-approval studies. This search identified 17 reports of possible anaplastic large cell lymphoma (ALCL) in women with breast prostheses. Although ALCL is extremely rare, the FDA believes that women with breast prostheses may have a very small but increased risk of developing this disease in the scar capsule adjacent to the prosthesis. Based on available information, it is not possible to confirm with statistical certainty that breast protheses cause ALCL. Currently, it is not possible to identify a type of prosthesis (silicone gel versus saline) or a reason for implantation (reconstruction versus aesthetic augmentation) associated with a smaller or greater risk. When ALCL occurs, it has been most often identified in patients undergoing prosthesis revision procedures for late-onset, persistent seroma. Because it is so rare and most often identified in patients with late onset of symptoms such as pain, lumps, swelling, or asymmetry, it is unlikely that increased screening of asymptomatic patients would change their clinical outcomes. The FDA does not recommend prophylactic breast prosthesis removal in patients without symptoms or other abnormalities. A patient with suspected ALCL should be referred to an appropriate specialist for evaluation. When testing for ALCL, fresh seroma fluid and representative portions of the capsule should be collected and sent for pathology tests to rule out ALCL. Diagnostic evaluation should include cytologic evaluation of seroma fluid with Wright-Giemsa–stained smears and cell block immunohistochemistry testing for cluster of differentiation and anaplastic lymphoma kinase markers. Any confirmed cases of ALCL in women with breast prostheses must be reported to the FDA.

Question 96

A 45-year-old woman comes for evaluation 1 year after undergoing vertical mastopexy without placement of prostheses because she thinks her breasts have started to sag. An increase in which of the following breast dimensions has most likely occurred since the patient's last visit? A) Breast base diameter B) Nipple to inframammary crease C) Nipple-areola diameter D) Suprasternal notch to inframammary crease E) Suprasternal notch to nipple

Answer 96

The correct response is Option B. The nipple-to-inframammary crease dimension is most likely to increase over time. This leads to pseudoptosis (bottoming out) and the appearance of a sagging breast. Pseudoptosis occurs when the breast gland migrates lower than the inframammary crease while the nipple stays in normal position. It is essential that patients be informed that their breasts will eventually sag following mastopexy. Procedures to prevent this from occurring include the use of permanent mesh encircling the breast mound. Mastopexy and reduction mammaplasty share similar operative strategies as well as complications. All techniques suffer bottoming out to different degrees. Breast base diameter will change very little over time as long as the breast volume remains constant; eg, weight gain can increase breast volume. An increase in the nipple-areola diameter is unlikely with vertical mastopexy; however, increased areola diameter is associated with periareolar mastopexy. To minimize this complication, a permanent purse-string suture is recommended. Suprasternal notch-to-inframammary crease distance changes very little in comparison with the nipple-to-inframammary crease distance. The suprasternal notch-to-nipple distance changes very little postoperatively. When a prosthesis is used during mastopexy, this distance will increase; however, the nipple-to-inframammary crease will usually increase to a greater extent.

Question 97

A 45-year-old woman comes to the office for consultation regarding augmentation mammaplasty. She wears a size 32B brassiere; height is 5 ft 3 in (160 cm), and weight is 130 lb (59 kg). Subglandular placement of saline prostheses is planned. Which of the following is the primary advantage of using saline rather than silicone prostheses in this patient? A)Easier detection of rupture BLess capsular formation C)Less wrinkling D)Lighter prosthesis E)Lower risk of leakage

Answer 97

The correct response is Option A. Although both silicone and saline prostheses rupture at a similar rate, a saline rupture is more easily detectable because the saline is resorbed in the body. The deflated breast will be smaller in volume. Subtle changes, such as decreased upper pole fullness or increased softness, may be the only clues to silicone rupture on physical examination. Ultrasonography or MRI may be needed to confirm the diagnosis. Saline prostheses are firmer than silicone; they are more likely to be palpable than silicone prostheses as well. Neither prosthesis has been associated with systemic immune syndromes, and both prostheses produce capsular contracture, wrinkling, and leakage.

Question 98

A 28-year-old woman comes for follow-up evaluation 2 weeks after undergoing bilateral augmentation mammaplasty with subpectoral placement of 325-mL, round, smooth saline prostheses. She is now concerned that both prostheses appear “too high.” Physical examination shows fullness in the upper quadrants of both breasts. Which of the following interventions is most appropriate? A)Administration of oral zafirlukast B)Application of a circumferential breast band C)Injection of corticosteroid into the inframammary crease D)Open capsulotomy E)Percutaneous release of the inframammary crease

Answer 98

The correct response is Option B. The most appropriate recommendation is breast band application. Breast shape following augmentation mammaplasty undergoes dynamic changes. The skin envelope and pectoralis muscle stretch under the expansion pressure of the prosthesis. The skin of the lower pole will stretch, allowing the prostheses to migrate inferiorly. Breast massage and a circumferential elastic breast band applied around the superior breast encourage this migration. Zafirlukast is a leukotriene-antagonist that is used for the treatment of asthma. Preliminary studies suggest improvement in capsule contractures. This drug is associated with potential life-threatening liver complications as well as neuropsychiatric events. Because administration in the scenario described would constitute an off-label use of the drug, extensive discussion with the patient would be required prior to use. In the past, steroid was injected into the saline compartment of a double-lumen prosthesis in an attempt to decrease the incidence of capsule contraction. This delivery system was uncontrolled and many prostheses migrated beyond the normal limits of the inframammary crease. Postoperative steroid injection has been used with some success for the prevention of recurrent capsule contracture following capsulectomy. If residual inferior pectoralis muscle fibers are left intact along the rib or capsule contracture develops, open capsulotomy may be required; however, conservative treatment is indicated at this early postoperative period. Percutaneous release would expose the patient to unnecessary complications of prosthesis injury, bleeding, and inframammary crease malposition.

Question 99

A 40-year-old woman comes to the office because of firmness of the right breast. Twenty years ago, she underwent augmentation mammaplasty with smooth silicone prostheses placed in subglandular pockets. Which of the following is the most appropriate management? A)Injection of corticosteroids B)Treatment with zafirlukast (Accolate) C)Closed capsulotomy D)Open capsulotomy E)Total capsulectomy

Answer 99

The correct response is Option E. In the patient described with a capsular contracture, the most appropriate option is open capsulectomy. As opposed to open capsulotomy, open capsulectomy removes the entire capsule. Leaving the capsule behind in open capsulotomy can contribute to late seromas. Scar tissue left behind during an open capsulotomy may also prevent the prosthesis and breast from obtaining a natural shape. Closed capsulotomy is no longer advised for breast prostheses because of the risk of rupturing the prosthesis during the procedure. Open capsulotomy and open capsulectomy with replacement of the prosthesis in the subglandular plane will continue to be associated with higher capsular contracture rates than submuscular or dual-plane placement. These are options for the patient as long as she understands the trade-offs of keeping the prosthesis in this plane. Zafirlukast (Accolate) is a leukotriene receptor antagonist that is used as a bronchodilator in the management of asthma. The evidence supporting its use in capsular contracture is anecdotal. It is not approved by the US Food and Drug Administration (FDA) for use in capsular contracture; therefore, its use in the scenario described would be considered an ?off-label? indication. As such, zafirlukast cannot be recommended for the routine treatment of capsular contracture.

Question 100

A 24-year-old woman comes to the office 8 months after undergoing a circumareolar mastopexy/augmentation. She is concerned because her areolas are now asymmetric. They were symmetric preoperatively. Physical examination shows that the right areola diameter is 7 cm and the left areola diameter is 4 cm. The most likely cause of this asymmetry is a failure of which of the following? A)Breast pillar approximation B)Periareolar de-epithelialization C)Prosthesis pocket D)Purse-string suture E)Skin envelope tailor tacking

Answer 100

The correct response is Option D. The most likely cause of nipple-areola asymmetry in the patient described is failure in the purse-string suture. Periareolar mastopexy/augmentation has been plagued with inconsistent control of the nipple-areola complex diameter. This mastopexy technique creates concentric resection of periareolar epithelium to elevate the nipple-areola complex and reduce the skin envelope. The etiology of this areola-spreading is the tension of the closure intrinsic to the technique. Use of a permanent suture for the purse-string helps limit the postoperative spreading of the areolar diameter. Introduction of the interlocking polytetrafluoroethylene (GORE-TEX) suture has allowed improved control of areolar shape and diameter. If one of the purse-string sutures breaks or pulls through its dermal attachments, that areola will be subject to the forces of tension and expand in diameter. In the patient described, operative correction involves either replacing the purse-string on the widened side or removing the purse-string on the smaller diameter areola. Periareolar de-epithelialization is the cause of the tension and is an essential part of the procedure. In patients who are significantly asymmetric, tension of the areolas will also be asymmetric; however, a permanent purse-string suture is crucial in these cases. Prosthesis pocket and parenchyma shaping sutures will not have the impact on areolar diameter that is described in this scenario. Envelope tailor tacking relates to final adjustments in periareolar de-epithelialization.

Question 101

A 32-year-old woman comes to the office for consultation regarding augmentation mammaplasty. She is concerned about the potential complications with the use of silicone gel prostheses within the first 5 years postoperatively. Which of the following is the most commonly reported complication of the implantation of cohesive silicone gel breast prostheses? A)Capsular contracture B)Granuloma C)Hematoma D)Infection E)Rupture

Answer 101

The correct response is Option A. Cohesive silicone gel is a breast prosthesis option that has been approved by the FDA since 2006. Cohesive gel prostheses have also been called ?gummy bear? prostheses. They maintain their shape because of the increased cross-linking within the silicone gel. A study by Cunningham followed 1008 patients and 1898 cohesive gel prostheses. Rupture rate was 1.1% for aesthetics and 3.8% for reconstructive procedures. Capsular contracture rates (Baker III/IV) were 9.8/13.7%, and infection was 1.6/6.1%, respectively. Thus, capsular contracture was the most common of the listed complications. The reported incidence of hematoma is approximately 2%. It should be noted that complications occur more commonly in primary reconstruction as compared to primary augmentation. These findings are important in the preoperative counseling of patients.

Question 102

A 36-year-old woman comes to the office for consultation regarding augmentation mammaplasty. She wears a size 34B brassiere and wants the size increased to a full C cup. Height is 5 ft 6 in (168 cm) and weight is 126 lb (57 kg). She feels her breasts are reasonable in appearance but has been encouraged by her husband, from whom she is separated, to seek enhancement. The risks of the surgery, including loss of nipple-areola sensation and the need for prosthesis maintenance over time, are discussed. She opts to proceed with surgery, and 375-mL saline breast prostheses are placed subpectorally through inframammary fold incisions. Which of the following is most likely to cause patient dissatisfaction after the procedure? A ) Continued separation from her husband B ) Deflation of the breast prostheses C ) Hypertrophy of the breast scars D ) Inability to breast-feed E ) Inadequate breast size

Answer 102

The correct response is Option A. Thorough patient evaluation before surgery, including screening, discussion of risks and complications, and the need for realistic expectations, is necessary to optimize patient satisfaction after surgery. This is especially true of aesthetic surgery. Despite these efforts, patient dissatisfaction occurs and can be extremely difficult to manage. Patient dissatisfaction is usually associated with failures in communication and patient selection criteria. Determining which patients are unsuitable for operation is a skill acquired with experience. General guidelines include patients who (1) have unrealistic expectations, (2) are excessively demanding, (3) have dissatisfaction with a previous surgical procedure, (4) are psychologically unstable, and (5) have a minimal deformity. In the scenario described, the patient has an unrealistic expectation that the surgery might save her marriage. Because of her motivation for surgery, she is unlikely to be happy, despite a very good result, unless the expectation of reconciliation has been fulfilled. The other options are possible causes of postoperative dissatisfaction; however, preoperative counseling and education of the potential complications allow for enhanced acceptance if they do occur.

Question 103

A 47-year-old woman is referred by her primary care physician to evaluate a suspected intracapsular rupture of her prosthesis on the left identified during routine mammography. She underwent primary augmentation mammaplasty with subglandular placement of single-lumen silicone breast prostheses in 1990. Physical examination shows a smaller breast on the left. An MRI is requested. Which of the following findings on MRI is most likely to confirm the diagnosis? A ) Double wall sign B ) Linguine sign C ) Multiple echogenic lines D ) Reverse double-lumen sign E ) Snowstorm sign

Answer 103

The correct response is Option B. MRI, mammography, ultrasonography, and CT scanning have all been used to diagnose silicone breast prosthesis rupture. Although each modality has specific strengths and weaknesses that may make a particular modality the study of choice for an individual patient, MRI of silicone breast prostheses reports the highest sensitivity and specificity for detection of silicone prosthesis rupture. Of the options listed, only the linguine sign is consistent with intracapsular silicone prosthesis rupture and represents the prosthesis shell floating in free silicone gel. The double wall sign, also known as Rigler sign, is a radiographic sign of pneumoperitoneum. Snowstorm sign and echogenic lines may be seen on ultrasound examination. Water suppression or a reverse double-lumen sign would not be expected findings in a single-lumen device but may have a role in double-lumen devices.

Question 104

A 26-year-old woman comes to the office for consultation regarding right mammary hypoplasia and a superiorly displaced nipple-areola complex. Examination shows a depressed right chest wall. The pectoralis major muscle is anatomically normal. Which of the following is the most likely diagnosis? A ) Anterior thoracic hypoplasia B ) Pectus carinatum C ) Pectus excavatum D ) Poland syndrome E ) Sternal cleft

Answer 104

The correct response is Option A. The most likely diagnosis in this patient is anterior thoracic hypoplasia. Anterior thoracic hypoplasia is a syndrome composed of an anterior chest wall depression resulting from posteriorly displaced ribs, hypoplasia of the ipsilateral breast, and a superiorly displaced nipple-areola complex. The sternum is in normal position, and the pectoralis major muscle is normal. Pectus excavatum is the most common congenital chest wall abnormality in which the ribs and sternum form abnormally, resulting in a concave anterior chest wall. Typically, the lower third of the sternum is involved. In the most severe form, pectus excavatum can present with the sternum adjacent to the vertebral bodies associated with cardiopulmonary abnormalities. In contrast, pectus carinatum is a chest wall deformity in which the sternum and ribs are forced anteriorly, creating the appearance of a €œpigeon €™s chest. € Pectus excavatum and carinatum have sternal involvement, but they do not involve changes in the development of the breast. Poland syndrome is a congenital anomaly characterized by a number of unilateral findings. The classic features of Poland syndrome include absence of the sternal head of the pectoralis major, hypoplasia and/or aplasia of the breast or nipple, deficiency of subcutaneous fat and axillary hair, abnormalities of the rib cage, and upper extremity anomalies. In its simplest form, Poland syndrome may present with only mild hypoplasia of the breast and lateral displacement of the nipple. Complex presentations of Poland syndrome include hypoplasia or aplasia of the chest wall musculature (serratus, external oblique, pectoralis minor, and latissimus dorsi muscles) or total absence of the anterolateral ribs with herniation of the lung. Sternal cleft is a rare congenital defect of the anterior chest wall resulting from a failure of midline fusion of the sternum. Depending on the degree of clefting, there are complete and incomplete forms. The sternal cleft is clinically significant because of the potential for the lack of protection to the heart and great vessels. Sternal clefts are not associated with aplasia or hypoplasia of the breast.

Question 105

A 20-year-old woman comes to the office for consultation regarding augmentation mammaplasty. Height is 5 ft 4 in (163 cm) and weight is 120 lb (54 kg). Physical examination shows mammary hypoplasia. She currently wears a size 34B brassiere and would like to wear a size C brassiere. Which of the following is the most appropriate option for breast enhancement? A ) Autologous fat transfer B ) Breast Enhancement and Shaping System (BRAVA) C ) Saline prostheses D ) Smooth gel prostheses E ) Textured gel prostheses

Answer 105

The correct response is Option C. Augmentation mammaplasty is one of the most common plastic surgery operations. During the moratorium on silicone gel prostheses between 1992 and 2006, the saline breast prosthesis became the prosthesis of choice. When a saline prosthesis ruptures, it decreases in size as the saline leaks out and is absorbed by the body. The deflated side is usually noticeable to the patient and can be compared to the nondeflated side for further distinction. The saline may leak out slowly, taking a week or longer to be noticeable. When the Food and Drug Administration lifted the moratorium on silicone gel prostheses, it stipulated that women must be 22 years of age to use the gel prosthesis. Therefore, for the patient described, the only option is saline. Saline prostheses are firm to the touch, and on very thin patients the normal rippling can be palpated through the skin, especially noticeable along the lower, outer pole where there is no pectoral muscle coverage. Autologous fat transfer is reported in the literature but would be difficult to do on this very thin patient. Harvesting enough fat to achieve the goal of a size C brassiere would be difficult. The BRAVA system can increase breast size but only minimally, so it is unlikely that this would give the patient enough volume for her goal of a size C brassiere. The deflation rate of saline prostheses is debated in the literature, related to prosthesis type (textured versus smooth), fill volumes, and physician technique. It is agreed that the expected lifespan of the saline prosthesis is 10 years.

Question 106

A 42-year-old woman with Grade 3 ptosis of the breasts is scheduled to undergo augmentation mammaplasty and mastopexy. Which of the following operative decisions is most likely to have an adverse effect on the outcome of the procedure? A ) Augmentation mammaplasty and use of vertical mastopexy technique B ) Augmentation mammaplasty and use of a Wise-pattern mastopexy technique C ) Mastopexy and placement of 450-mL saline prostheses in a dual-plane pocket D ) Mastopexy and placement of 200-mL silicone prostheses in a subpectoral pocket E ) Performance of the operation in two stages

Answer 106

The correct response is Option C. Augmentation mammaplasty and mastopexy is a complex procedure that can increase the risks and difficulties beyond those of each one performed independently. A mastopexy is designed to raise the nipple-areola complex and reshape the breast by resecting skin and tightening the parenchyma. In direct opposition to this shaping, an augmentation enlarges the volume of the breast and expands the skin envelope. Further, mastopexy techniques involve elevation of flaps that require adequate vascularity, while prosthesis placement devascularizes the breast and puts direct pressure on the remaining circulation. The larger the prosthesis, the greater the adverse effect on vascularity. This can lead to early problems with nipple-areola complex loss, skin flap loss, prosthesis infection and exposure, and resultant deformities. Larger prostheses are also associated with long-term complications of soft-tissue attenuation. This results in tissue thinning, stretching, atrophy, rippling, and recurrent ptosis. Despite conflicting studies, prosthesis size of 350 mL is considered the crossover to large prostheses. Despite these risks, most patients want to have both operations performed simultaneously. If these patients are accepted, it is the surgeon €™s responsibility to minimize complications. Some surgeons prefer to perform augmentation and mastopexy in two separate operations to control the result and reduce the complication rate. Placement of 200-mL silicone prostheses in a subpectoral pocket is less likely to cause problems because of their modest size. Vertical mastopexy and Wise-pattern techniques are both acceptable procedures that can be applied to patients with Grade 3 ptosis.

Question 107

Which of the following innervates the nipple-areola complex? A ) Intercostal B ) Lateral pectoral C ) Long thoracic D ) Supraclavicular E ) Thoracodorsal

Answer 107

The correct response is Option A. The classic teaching ascribes nipple innervation to the fourth intercostal nerve. More recent anatomical studies have confirmed that the nipple is innervated by a rich subdermal plexus of nerves that provide both tactile and pressure sensation. This plexus receives innervation from the lateral and anterior cutaneous branches of the second to fifth intercostal nerves. This plexus explains why the nipple can retain sensation despite extensive surgical procedures. The lateral pectoral innervates the pectoralis major muscle. The long thoracic innervates the serratus anterior muscle. The supraclavicular innervates the skin of the upper breast. The thoracodorsal innervates the latissimus dorsi muscle.

Question 108

Which of the following sequelae is more likely to result from the use of textured silicone gel prostheses rather than smooth silicone gel prostheses? A ) Capsular contracture B ) Hematoma C ) Malposition D ) Rippling E ) Rupture

Answer 108

The correct response is Option D. The use of textured prostheses is associated with a significant rate of rippling when compared with smooth prostheses. One study reported over a two-fold increase. Visible rippling can be minimized with subpectoral implantation as well as by limiting the use of these prostheses to patients with more native breast tissue. Rippling is more pronounced with saline-filled prostheses. Rippling occurs when the breast skin and soft tissue are thin. This rippling will worsen with time because of the skin stretching and thinning. The key to treatment is to thicken the breast skin or change the prosthesis characteristics. Overinflation of saline prostheses is thought to minimize rippling; however, one recent study did not show any difference in the incidence of rippling in underfilled saline prostheses. Surgical treatment for rippling is usually incomplete. Dermal grafts have been used with some success to thicken the rippled breast skin. Changing a saline prosthesis to a cohesive silicone gel prosthesis will also improve rippling. Various flaps can also be used to reinforce the thinned breast skin. Textured surface prostheses are superior to smooth prostheses in decreasing capsular contracture. However, this advantage is minimal when using saline prostheses in a subpectoral pocket. The incidence of hematoma formation is similar for both types of prostheses. Rupture rates for textured gel and saline gel are similar; however, textured saline prostheses have a higher rate of deflation than smooth saline prostheses. Malposition rates are not higher with the use of textured prostheses.

Question 109

A 40-year-old nulliparous woman comes to the office because she is dissatisfied with the "saggy" appearance of her breasts following a 120-lb (54-kg) weight loss. Physical examination shows bilateral Grade 3 ptosis. Which of the following additional findings on examination of the breasts is most likely in this patient? A ) Flatness of the upper pole B ) High inframammary fold C ) Lack of axillary fat roll D ) Lack of excess skin E ) Laterally displaced areolas

Answer 109

The correct response is Option A. The types of breast deformities seen following massive weight loss are relatively new. To adequately manage these patients and assess outcomes, it is important to understand the defect. Classification systems exist for breast ptosis for other causes; however, these are based mainly on nipple position. Breast deformities after massive weight loss vary significantly. Patients typically present with severe breast ptosis (Grade III), medialization of the nipple-areola complex, lateralization of the breast mound, and extension to a lateral axillary fat roll, which often extends well into the back. The inframammary fold is often in a lower position because of deflation of the entire skin and connective tissue envelope. Beyond the typical breast changes of glandular tissue loss and ptosis, there tends to be more asymmetrical volume loss in the massive weight loss breast, and there is more of a deflated and flat appearance of the breast (particularly a flat upper pole). Skin laxity is very apparent, and the degree of excess skin can be significant.

Question 110

A 24-year-old woman is undergoing endoscopic transaxillary augmentation mammaplasty. Which of the following is most appropriate to preserve sensation in the medial aspect of the upper extremity? A ) Avoiding dissection into the axillary fat B ) Blunt dissection near the clavicle C ) Identification of the sensory nerves within the axilla D ) Positioning of the prosthesis subpectorally E ) Preservation of the lateral pectoral nerve

Answer 110

The correct response is Option A. During transaxillary augmentation mammaplasty, prevention of sensory changes to the medial aspect of the upper extremity requires a subdermal dissection and avoids dissection into the axillary fat. Branches of the intercostobrachial and medial brachial cutaneous nerves provide sensory innervation to the medial upper extremity. Both nerves course superficially through the axillary fat posterior to the lateral border of the pectoralis major muscle. Dissection within the axillary fat risks injury to these nerves with subsequent anesthesia or paresthesia of the inner arm. Identification of the nerves within the axilla requires dissection into axillary fat and risks injury to the sensory nerves. Sensory innervation to the medial aspect of the upper extremity is not affected by the positioning of the prosthesis (subpectoral versus subglandular) or dissection near the clavicle. The lateral pectoral nerve provides motor innervation to the lower third of the pectoralis major muscle.

Question 111

A 35-year-old woman comes to the office for consultation regarding augmentation mammaplasty. A preoperative mammogram is most indicated if the patient's history includes which of the following? A ) A grandmother diagnosed with breast cancer at age 73 years B ) A mother diagnosed with breast cancer at age 45 years C ) Personal history of breast cysts D ) Personal history of fibroadenoma E ) A sister diagnosed with ovarian cancer

Answer 111

The correct response is Option B. Among the risk factors for breast cancer, family history is the most significant. It can be divided into two broad categories: familial breast cancer, which most likely results from changes in multiple low penetrance genes coupled with environmental influences, and hereditary breast cancer, which results in high penetrance mutation in a single gene. Familial breast cancer is relatively common and conveys a modest elevation in risk compared with genetic breast cancer, which is rare but associated with high risk. A family history of breast cancer has been demonstrated to increase the risk of breast cancer in multiple studies. Breast cancer in a first-degree relative increases the risk of breast cancer, and that risk decreases as the age of the affected relative increases (ie, it is a 2.3 relative risk factor if the affected relative is under 50 years of age; it is 1.8 if she is over 50). Individuals whose first-degree relatives have bilateral breast cancer have an increased risk of 5.5 times the normal population.

Question 112

A 48-year-old woman comes to the office because she is dissatisfied with the "sagging" appearance of her breasts. Physical examination shows the location of the nipples 1 cm above the inframammary fold bilaterally. The majority of breast tissue is below the fold. Which of the following is the most likely diagnosis? A ) Grade 1 ptosis B ) Grade 2 ptosis C ) Grade 3 ptosis D ) Pseudoptosis

Answer 112

The correct response is Option D. Regnault defined the degree of ptosis by evaluating the relationship of the nipple to the inframammary fold. In pseudoptosis, the nipple is above or at the level of the inframammary fold, with the majority of the breast tissue below. This gives the impression of ptosis. In Grade 1, or mild ptosis, the nipple is within 1 cm of the level of the inframammary fold and above the lower contour of the breast and skin envelopes. In Grade 2, or moderate ptosis, the nipple is 1 to 3 cm below the inframammary fold but above the lower contour of the breast and skin envelopes. In Grade 3, or severe ptosis, the nipple is more than 3 cm below the inframammary fold and below the lower contour of the breast and skin envelopes.

Question 113

A 25-year-old woman comes to the office because she has a lump in her right armpit. She reports that the lump increases in size and becomes tender during her period. She also says that it restricts arm movement and interferes with her ability to play tennis, especially during menses. Examination shows a 4 \* 4-cm, soft, mobile mass in the right axilla that is tender to palpation. There is no evidence of firmness or palpable nodules within the mass. Which of the following is the most appropriate next step in management? A ) Excision of axillary tissue B ) Fine-needle aspiration C ) Incisional biopsy D ) Mammogram E ) Sentinel lymph node biopsy

Answer 113

The correct response is Option A. Axillary accessory breast tissue should be removed surgically. It is found in 0.4% to 6% of women and may be asymptomatic, cause pain, restrict arm movement, or cause cosmetic problems or anxiety. There have been reports of malignant degeneration of this accessory breast tissue, and the current recommendations are for simple excision through an axillary incision. Fine-needle aspiration may diagnose the presence of breast tissue, but it also may be inconclusive. A mammogram would not be helpful in confirmation of this diagnosis; however, MRI has been used to evaluate the presence of axillary breast tissue. A sentinel lymph node biopsy would not be necessary given the lack of malignancy. An incisional biopsy taking a sample of tissue is unnecessary, as the lesion should be completely excised.

Question 114

A 24-year-old woman comes to the office one year after undergoing secondary augmentation mammaplasty because she reports that with manipulation she €œcan move each breast to the other side. € Physical examination shows that each breast prosthesis can be moved across the chest midline. Which of the following is the LEAST likely cause of this finding? A ) Multiple procedures B ) Preexisting chest wall deformity C ) Prostheses with large base diameter D ) Saline prostheses E ) Subpectoral positioning

Answer 114

The correct response is Option D. Synmastia is defined as any situation in which the breast prosthesis crosses the midline, even if it is only on one side. This relatively rare complication is at some times obvious and at other times more subtle, requiring breast manipulation to become apparent. There is no correlation with the use of either silicone- or saline-filled prostheses. The complication is more common in cases in which large prostheses with large base diameters are used, in multiple successive enlargement procedures, when there is a preexisting chest wall deformity, and with the subpectoral positioning of prostheses.

Question 115

A 35-year-old woman, gravida 3, para 3, comes to the office for consultation about augmentation mammaplasty with gel prostheses. During the visit, she inquires about the safety of breast-feeding after augmentation mammaplasty with silicone prostheses. She should be informed that the silicone levels in her breast milk after the augmentation will be which of the following? A ) Similar to the levels in the milk of patients with no prostheses B ) Higher than the levels in the milk of patients with no prostheses C ) Similar to the levels in commercially available infant formula D ) Higher than the levels in commercially available infant formula

Answer 115

The correct response is Option A. A study by Semple and colleagues compared silicone levels in milk from lactating women with and without prostheses. Mean silicone levels in breast milk of augmented and nonaugmented women were not significantly different (55 ng/mL and 51 ng/mL, respectively). The silicon particle was used as a proxy of silicone. Interestingly, silicone levels were significantly higher in commercially available infant formulas (4402.5 ng/mL). This study was performed in patients with second-generation gels in the 1990s; third-generation cohesive prostheses have not been tested, although they are likely to have a lower or similar level.

Question 116

A 36 €‘year-old woman comes to the office for consultation regarding mastopexy. She will not consider use of prostheses and is concerned about the length of the scars. Photographs of the breasts are shown. Which of the following types of mastopexy is most appropriate for this patient? (A) Circumareolar (B) Crescent (C) Vertical (D) Wise €‘pattern

Answer 116

The correct response is Option C. The most appropriate management for the patient described, who has grade 2 ptosis of the breasts, is a vertical mastopexy. The procedure will leave periareolar and vertical scars but will give the patient a longer-lasting result than a periareolar procedure. Ptosis is graded on a scale of 1 to 3, depending on nipple position changes from above or below the level of the inframammary crease. In pseudoptosis, the nipple is above or at the level of the crease, but the majority of breast parenchyma has descended and is distributed below the inframammary fold. In grade 1 ptosis, the nipple position is within 1 cm of the level of the inframammary fold. In grade 2 (moderate ptosis), the nipple is clearly below the fold (1 to 3 cm) but above the lowest part of the breast. In grade 3 ptosis, the nipple is greater than 3 cm below the inframammary fold and below the lower contour of the gland. In grade 1 ptosis, subglandular augmentation is often adequate. Alternatively, if the patient does not desire implants, a dermal or crescent mastopexy, which involves excision of a crescent-shaped area of skin above the areola, may be necessary. Circumareolar mastopexy, which involves concentric excision of skin and leaves no vertical scar beneath the areola, is also adequate for grade 1 ptosis. Periareolar resections without implant placement tend to flatten the shape of the breast. A vertical or infraareolar mastopexy is ideal for grade 2 or moderate ptosis. Wise €‘pattern mastopexy is appropriate for grade 3 ptosis with large amounts of skin excess, but the procedure will leave an inverted T €‘shaped scar.

Question 117

Which of the following most appropriately describes the biomechanical characteristic specifically designed to minimize gel diffusion in a third-generation silicone prosthesis? A ) Increased cross-linking of silicone elastomer B ) Increased molecular weight of silicone gel C ) Internal barrier coating D ) Texturing of prosthesis surface

Answer 117

The correct response is Option C. Several generations of silicone gel breast prostheses have been manufactured since the early 1960s. Third-generation prostheses manufactured since 1986, and recently FDA-approved for cosmetic and reconstructive procedures in the United States, were specifically developed to address the more common problems associated with second-generation prostheses, including silicone bleed. While a number of biomechanical properties were altered, the modification that was specifically designed to reduce silicone bleeding was the addition of an inner barrier on the elastomer shell. This barrier changed the solubility characteristics of the shell, thus inhibiting the diffusion of silicone through it. McGhan Medical released a prosthesis that had a diphenyl silicone copolymer barrier layer between an inner and outer layer of high-performance elastomer (Intrashiel). The Dow-Corning Silastic II prosthesis had a fluorosilicone copolymer layer to restrict silicone bleed. The design of silicone gel breast prostheses has evolved significantly since their first introduction. First-generation prostheses had thick shell walls, viscous gel, and Dacron patches. Hardness and contracture were major complaints. To address these issues, second-generation prostheses were developed (1973-1985), which had thinner walls and lower viscosity gel. The result was a softer, more natural-feeling prosthesis in the early postoperative period. Second-generation prostheses had the highest rates of rupture, bleed, and capsular contracture, and as a result, third-generation prostheses reintroduced thicker shells and more cohesive gel. Increasing the cross-linking of the silicone elastomer strengthens and thickens the wall of the prosthesis. Texturing of the prosthesis surface was a strategy designed to decrease the rate of capsular contracture.

Question 118

A 28-year-old woman is scheduled to undergo release of severe cicatricial contraction six months after removal of an infected breast prosthesis. Preoperative physical examination shows that soft tissue is required in the inframammary area. Closure with a submammary flap is planned. Which of the following vessels is most likely to supply blood to this flap? (A) Internal mammary perforators (B) Lateral thoracic artery (C) Superficial inferior epigastric artery (D) Thoracoacromial perforators (E) Thoracodorsal perforators

Answer 118

The correct response is Option A. The sequelae of infection in breast augmentation can be severe cicatricial contraction of the inferior pole of the breast. Reoperation can be considered after an appropriate interval of six months, which allows for resolution of inflammation and scar maturation. If additional soft tissue is required, submammary flaps (with good color and texture match) can be used from the medial or lateral base of the breast. The blood supply is based medially on perforators of the internal mammary or superior epigastric arteries and laterally from perforators of the intercostal vessels. The lateral thoracic artery is the blood supply for a lateral chest flap, which would not be able to contribute any meaningful amount of soft tissue to the submammary area. The superficial inferior epigastric artery is the basis of lower abdominal flaps and has no role as a local flap for breast surgery. The thoracoacromial perforators are associated with extended cheek/neck flaps for head and neck reconstruction. Thoracodorsal perforators are the basis of thoracodorsal perforator flaps and would not be able to contribute soft tissue to the submammary area.

Question 119

A 26-year-old woman who underwent augmentation mammaplasty six months ago comes to the office because she has numbness of the right nipple. The most likely cause is injury to which of the following intercostal nerves? A ) Second B ) Third C ) Fourth D ) Fifth E ) Sixth

Answer 119

The correct response is Option C. According to Courtiss and Goldwyn, the fourth intercostal nerve is the most important nipple innervator. The anterior cutaneous branches of the second through sixth intercostal nerves provide the medial innervation. The anterior rami of the lateral cutaneous branches of the third through sixth intercostal nerves provide the lateral innervation. It has been demonstrated that the lateral cutaneous branches of the third through fifth intercostal nerves and the anterior cutaneous branches of the second through fifth intercostal nerves all contribute to nipple supply. The lateral cutaneous branch of the fourth intercostal nerve has been traced into the nipple and found to have two branches. The deep branch passes inferolaterally on the pectoralis major fascia before coursing up into the areola, whereas the superficial branch passes up through the superficial parenchyma.

Question 120

Which of the following is the most likely site of ectopic breast tissue in a patient with ectopic polymastia? A ) Axilla B ) Costal margin C ) Dorsal thigh D ) Pubis E ) Vulva

Answer 120

The correct response is Option C. Polymastic breast tissue can be categorized either as accessory or ectopic. Ectopic breast tissue is found outside the milk line at such sites as the scalp, ear, back, shoulder, epigastrium, and posterior or dorsal thigh. Accessory polymastia occurs along the milk line. Greater than 90% of accessory breast tissue is localized to the chest region. The axilla, groin, vulva, and medial thigh may also be affected as well as regions above or below the normal breast, such as the costal margin.

Question 121

A 15-year-old girl is brought to the office for consultation regarding correction of breast asymmetry. Physical examination shows asymmetry of breast size and shape. The right breast is 90% smaller than the left breast. The right pectoralis major muscle is normal. The right nipple is present but smaller than the left nipple. Which of the following is the most likely diagnosis? A ) Amastia B ) Amazia C ) Athelia D ) Jeune syndrome E ) Poland syndrome

Answer 121

The correct response is Option B. Poland syndrome is characterized by unilateral hypoplasia or absence of the breast associated with deformities of the chest wall and ipsilateral hypoplastic or absent pectoralis major muscle. Amazia is characterized by absence of the glandular tissue only, while athelia is the absence of the nipple alone. Amazia can result from surgical removal of the breast bud, radiation, or congenital absence. In Jeune syndrome, the patient typically has a narrow immobile thorax, polychondrodystrophy, and renal disease. Amastia is the absence of both breast and nipple.

Question 122

A 36-year-old woman comes to the office for consultation regarding €œsagging € breasts 10 years after undergoing bilateral augmentation mammaplasty with subglandular placement of saline prostheses. Physical examination shows Grade 2 ptosis and an axillary scar. A mastopexy with capsulotomy and replacement of prostheses is planned. Which of the following pedicles is LEAST likely to preserve the blood supply to the nipple-areola complex? A ) Inferior B ) Medial C ) Superior D ) Superolateral E ) Superomedial

Answer 122

The correct response is Option A. Secondary mastopexy in the augmented patient can be particularly hazardous. In addition to scars from prior surgery, the soft-tissue envelope surrounding the prosthesis frequently becomes attenuated. Tebbetts observed that the €œconsequences of excessively large breast implants include ptosis, tissue stretching, tissue thinning, inadequate soft-tissue cover, [and] ...subcutaneous tissue atrophy. € Gravity causes most soft-tissue thinning and atrophy to eventually occur in the inferior pole of the augmented breast. Therefore, in secondary mastopexy augmentation procedures, blood supply to the nipple-areola complex should generally rely on a medial, superior, superomedial, or superolateral pedicle.

Question 123

A 36 €‘year-old woman comes to the office for consultation regarding mastopexy. She will not consider use of prostheses and is concerned about the length of the scars. Photographs of the breasts are shown. Which of the following types of mastopexy is most appropriate for this patient? (A) Circumareolar (B) Crescent (C) Vertical (D) Wise €‘pattern

Answer 123

The correct response is Option C. The most appropriate management for the patient described, who has grade 2 ptosis of the breasts, is a vertical mastopexy. The procedure will leave periareolar and vertical scars but will give the patient a longer-lasting result than a periareolar procedure. Ptosis is graded on a scale of 1 to 3, depending on nipple position changes from above or below the level of the inframammary crease. In pseudoptosis, the nipple is above or at the level of the crease, but the majority of breast parenchyma has descended and is distributed below the inframammary fold. In grade 1 ptosis, the nipple position is within 1 cm of the level of the inframammary fold. In grade 2 (moderate ptosis), the nipple is clearly below the fold (1 to 3 cm) but above the lowest part of the breast. In grade 3 ptosis, the nipple is greater than 3 cm below the inframammary fold and below the lower contour of the gland. In grade 1 ptosis, subglandular augmentation is often adequate. Alternatively, if the patient does not desire implants, a dermal or crescent mastopexy, which involves excision of a crescent-shaped area of skin above the areola, may be necessary. Circumareolar mastopexy, which involves concentric excision of skin and leaves no vertical scar beneath the areola, is also adequate for grade 1 ptosis. Periareolar resections without implant placement tend to flatten the shape of the breast. A vertical or infraareolar mastopexy is ideal for grade 2 or moderate ptosis. Wise €‘pattern mastopexy is appropriate for grade 3 ptosis with large amounts of skin excess, but the procedure will leave an inverted T €‘shaped scar.

Question 124

A 24-year-old woman comes to the office for consultation regarding surgical correction of the breast deformity shown above. Which of the following is the most appropriate management? (A) Augmentation with Wise-pattern mastopexy of both breasts (B) Augmentation with periareolar mastopexy of both breasts (C) Latissimus dorsi myocutaneous flap reconstruction of the left breast and periareolar mastopexy of the right breast (D) Extended dorsi myocutaneous flap reconstruction of the left breast and periareolar reduction of the right breast (E) Transaxillary augmentation of the left breast and periareolar mastopexy of the right breast

Answer 124

The correct response is Option B. The patient described has tuberous breast deformity, which is characterized by three components: herniation of the breast tissue into the nipple-areola complex with a cylindrical projection accompanied by a relatively large areola; deficiency of the lower pole of the breast in both vertical and horizontal axes; and hypoplasia. Periareolar mastopexy with augmentation will give access for radial-releasing incisions, which will allow expansion of the base of the breast and simultaneous areolar reduction. Wise-pattern mastopexy is indicated for more severe breast ptosis. Reconstruction with latissimus flap is a form of treatment for congenital chest wall deformities such as Poland syndrome. Contralateral reduction will not address the tuberous deformity problem. Transaxillary augmentation of the breast will not correct the nipple-areola complex or the constricted base.

Question 125

A 28-year-old woman is scheduled to undergo release of severe cicatricial contraction six months after removal of an infected breast prosthesis. Preoperative physical examination shows that soft tissue is required in the inframammary area. Closure with a submammary flap is planned. Which of the following vessels is most likely to supply blood to this flap? (A) Internal mammary perforators (B) Lateral thoracic artery (C) Superficial inferior epigastric artery (D) Thoracoacromial perforators (E) Thoracodorsal perforators

Answer 125

The correct response is Option A. The sequelae of infection in breast augmentation can be severe cicatricial contraction of the inferior pole of the breast. Reoperation can be considered after an appropriate interval of six months, which allows for resolution of inflammation and scar maturation. If additional soft tissue is required, submammary flaps (with good color and texture match) can be used from the medial or lateral base of the breast. The blood supply is based medially on perforators of the internal mammary or superior epigastric arteries and laterally from perforators of the intercostal vessels. The lateral thoracic artery is the blood supply for a lateral chest flap, which would not be able to contribute any meaningful amount of soft tissue to the submammary area. The superficial inferior epigastric artery is the basis of lower abdominal flaps and has no role as a local flap for breast surgery. The thoracoacromial perforators are associated with extended cheek/neck flaps for head and neck reconstruction. Thoracodorsal perforators are the basis of thoracodorsal perforator flaps and would not be able to contribute soft tissue to the submammary area.

Question 126

A 26-year-old woman is undergoing subglandular implantation of saline breast prostheses. Pinch test of the superior pole shows a thickness of 1 cm. This patient is most at risk for which of the following complications? (A) Capsular contracture (B) Double-bubble deformity (C) Infection (D) Numbness (E) Wrinkling

Answer 126

The correct response is Option E. The subglandular placement of breast prostheses has both advantages and disadvantages. Because the prostheses are closer to the skin, the patient €™s native skin and subcutaneous fat layer are the only coverage and must be carefully evaluated. Subglandular implants are less painful than other methods, and they age well with the breast. When evaluating the superior pole of the breast for adequate soft-tissue coverage, a minimum pinch test of 2 cm is recommended. Soft-tissue thickness of less than 2 cm will increase the chance of rippling and wrinkling with a subglandular placement. If the pinch test is less than 2 cm, submuscular placement is recommended for greater soft-tissue coverage of the prosthesis. Capsular contracture is rare with a saline implant. A double-bubble deformity occurs when the native glandular tissue lies at the lower pole of an implant, or when an implant falls below the inframammary fold. Infection and numbness are possible complications of implant surgery but are less common than wrinkling in a thin patient with subglandular implants.

Question 127

A 26-year-old woman comes to the office because she has pain and tenderness of the right breast three weeks after undergoing augmentation mammaplasty. The patient is satisfied with the appearance of the prostheses and does not want them permanently removed. Temperature is 39.0 °C (102.2 °F). She has chills and sweating. Physical examination shows induration of the right breast and drainage from the surgical incision. Gram stain of the drainage shows gram-negative rods. Which of the following is the most appropriate management? (A) Immediate hospitalization for intravenous antibiotic therapy (B) Oral antibiotic therapy and follow-up evaluation in three days (C) Removal of the implant, irrigation of the pocket, capsule debridement, and immediate reinsertion of new implant (D) Removal of the implant, irrigation of the pocket, capsule debridement, and reinsertion of new implant in six months (E) Removal of the implant, irrigation of the pocket, and immediate reinsertion of new implant

Answer 127

The correct response is Option D. The patient described has a severe infection with an elevated temperature, chills, diaphoresis, and signs of cellulitis. The Gram stain of the leaking fluid implicates involvement of the implant pocket. An infection of the implant pocket is difficult to control without removal of the implant. The most appropriate management is removal of the implant, irrigation of the pocket, debridement of the capsule, and reinsertion of an implant several months later. This approach minimizes the costs and risks associated with prolonged salvage attempts. Administration of antibiotics, either oral or intravenous, without drainage of the infected pocket is not likely to eradicate the infection. This treatment approach is indicated only for a superficial infection without involvement of the periprosthetic space. In patients with mild infection, with or without implant exposure, implant salvage can be considered. In this case, removal of the implant, irrigation of the pocket, capsule debridement, and immediate reinsertion of new implants can be performed. However, it should be noted that this approach can increase costs and risks, such as capsular contracture. In any case of implant removal, debridement of as much of the capsule as possible is recommended.

Question 128

A 22 €‘year €‘old woman comes to the office for consultation regarding correction of breast asymmetry. She says the problem is with the left breast; she is happy with the size and shape of the right breast. Physical examination shows narrowing of the left breast at the base. At the mid portion, the inframammary fold of the left breast is higher than that of the right breast. The left areola is enlarged. The cup size of the left breast is B, and the cup size of the right breast is C. Which of the following is the most appropriate management? (A) Augmentation mammaplasty of the left breast with radial scoring and areola reduction (B) Mastopexy of the left breast using a Wise-pattern technique with lowering of the inframammary fold (C) A pedicled TRAM flap to the left breast (D) Vertical reduction mammaplasty of the right breast

Answer 128

The correct response is Option A. The patient described has a tubular breast deformity. The most appropriate management is augmentation mammaplasty of the left breast with radial scoring and areola reduction. Contralateral reduction mammaplasty will not correct the shape of the affected breast. Reconstruction with a pedicled TRAM flap is quite aggressive for the patient described. A Wise-pattern mastopexy will not augment the volume and base of the affected breast.

Question 129

A 35-year-old woman, gravida 4, para 4, has undergone uncomplicated augmentation mammaplasty with silicone gel €“filled prostheses. According to prosthesis manufacturers and the United States Food and Drug Administration, which of the following is the recommended schedule of MRI screening to detect prosthesis rupture? (A) One year after surgery, then every two years (B) Two years after surgery, then every two years (C) Two years after surgery, then every three years (D) Three years after surgery, then every two years (E) Three years after surgery, then every three years

Answer 129

The correct response is Option D. Silicone gel €“filled prosthesis ruptures are most often silent. MRI screening is currently the best method to diagnose silent rupture. Often neither the physician nor the patient will know if the prosthesis has a tear or a hole in the shell, which is why the United States Food and Drug Administration recommends MRIs at three years postoperatively and then every two years thereafter to screen for rupture. Symptoms of silent rupture include hard knots or lumps surrounding the prosthesis or in the armpit; a change or loss of size or change in shape of the breast or prosthesis; and pain, tingling, swelling, numbness, burning, or hardening of the breast.

Question 130

A 35-year-old woman comes to the office because she is unhappy with the appearance of her right breast. She underwent implantation of a silicone prosthesis in the right breast 15 years ago to correct asymmetry. She has required three revision surgeries for severe capsular contracture. She wants to have the implant removed, but she also wants to retain symmetry of the breasts. Examination shows grade 3 capsular contracture in the right breast. Which of the following is the most appropriate management of the right breast after removal of the implant? (A) Excision of the capsule alone (B) Excision of the capsule and injection of aspirated fat (C) Excision of the capsule and insertion of a saline implant (D) Excision of the capsule and reconstruction with an autologous flap

Answer 130

The correct response is Option D. The patient described requires implant removal and capsulectomy to remove the firm scar tissue surrounding the implant. Reconstruction with an autologous flap is the most appropriate management to maintain volume and avoid capsular contracture. Implant removal, with or without capsulectomy, may treat the capsular contracture but will not leave her €œfull €‘breasted € as she desires. Even the use of textured or saline implants may cause capsular contracture. Injection of lipoaspirates is unpredictable and may cause calcifications and fat necrosis. Reconstruction with latissimus dorsi, TRAM, and DIEP flaps have all been described as methods of autologous breast augmentation and are good options to avoid implant problems.

Question 131

A 30-year-old woman undergoes augmentation mammaplasty with silicone gel prostheses. During the procedure, smooth prostheses are positioned subglandularly. The subglandular placement increases this patient=s risk of which of the following complications? (A) Capsular contracture (B) Double-bubble appearance (C) Infection of the implant (D) Rippling of the implant (E) Rupture of the implant

Answer 131

The correct response is Option A. Capsular contracture remains one of the main drawbacks to the use of silicone breast prostheses. Submuscular placement is a well-established method of reducing the rate of contracture. The introduction of implant-surface texturing in the late 1980s has greatly reduced the contracture rate for prostheses placed subglandularly. Development of capsular contracture is clearly more common in the first two years after subglandular implantation, regardless of the implant type. The large difference in the rate of contracture between textured and smooth prostheses in the subglandular position seems to be negligible in subpectoral placement; both types of implant have low contracture rates. The causes of capsular contracture and the effect of surface texturing and implant position in reducing its incidence are still not clear. Capsule formation is a normal response to the introduction of foreign material and, like most physiologic responses, varies by degree and timing. Additionally, there are general patient factors and local breast factors. The literature suggests that capsule response may be altered by other factors such as infection, diffusion of silicone gel, and smoking. The introduction of surface texturing alters the capsule response. Texturing may produce a more disorganized collagen pattern in the capsule. It has been suggested that subpectoral prostheses have a lower rate of capsular contracture, regardless of surface texturing, because of the massaging action of the overlying pectoralis major.

Question 132

A 32 €‘year-old woman who underwent submuscular placement of smooth 240-ml saline breast prostheses 10 years ago comes to the office for consultation regarding replacement of the implants. She says she wants her breasts to be two cup sizes larger. Currently, she wears a size 36C brassiere. Physical examination shows good aesthetic outcome and no evidence of capsular contracture or rippling. Which of the following is the most likely adverse effect of implant exchange in this patient? (A) Inability to breast-feed (B) Increased capsular contracture (C) Increased risk of breast cancer (D) Increased risk of collagen vascular disease (E) Shrinkage of breast tissue

Answer 132

The correct response is Option E. Patients seeking reoperation for dissatisfaction with breast size after initial implantation of breast prostheses must be informed of the following long €‘term negative effects: thinning of tissue, stretching of tissue, shrinkage of breast tissue, additional and more rapid sagging, palpable implant edges and shell, visible implant edges, visible traction rippling, and possible additional sensory loss. Shrinkage of breast tissue occurs with all prostheses; the larger the prosthesis, the more shrinkage that occurs. Larger implants will not give this patient a more natural appearance. The potential for lactation should not be impaired by breast prostheses, especially when the prostheses are positioned in the subpectoral pocket.

Question 133

A 52-year-old woman comes to the office because she has had progressive hardening of the left breast for the past two months. She underwent augmentation mammaplasty with implantation of saline-filled prostheses three years ago. On physical examination, the left breast is firm and elevated compared with the right. It is cool and painful. The patient €™s symptoms are most consistent with which of the following Baker classification levels? (A) I (B) II (C) III (D) IV

Answer 133

The correct response is Option D. Capsular contracture is the most likely cause of this patient €™s symptoms. Of the choices listed, only Class IV contracture would explain the malposition, pain, and firmness. In patients who have undergone breast augmentation, capsular contracture occurs in approximately 5% to 7% at one year after the procedure and in approximately 18% at three years postoperatively. Baker originally classified contracture of breast implants into four categories: Baker Classification of Capsular Contracture After Breast Augmentation Class I Normal breast; augmentation is not noticeable Class II Minimal contracture; the implant can be palpated but is not visible Class III Moderate contracture; the implant is palpable and distortion is visible Class IV Severe contracture; the breast is distorted, hard, cool, and painful Other common reasons for augmentation revision include patient request for size or shape change (30%), leakage or deflation (20%), contracture (18%), wrinkling (5%), and infection (5%).

Question 134

A 38-year-old woman comes to the office for consultation regarding surgical correction of sagging of the breasts. She breast-fed three children during the past five years; her youngest child was weaned two years ago. Physical examination shows second-degree ptosis. For this patient, which of the following is an advantage of mastopexy with augmentation over mastopexy alone? (A) Decreased risk of loss of nipple sensation (B) Decreased risk of nipple malposition over time (C) Decreased stretch deformity of surgical scars (D) Increased longevity of correction of ptosis (E) Increased upper pole volume

Answer 134

The correct response is Option E. The combination of implantation of a prosthesis with mastopexy can enhance the size and contour of the breast. This procedure often reduces the length of the incisions required to correct the ptosis because of the volume enhancement delivered by the implant. There is no known difference in the degree of loss of sensation between the two methods. The weight of the prosthesis places additional tension at the site of incision, causing more rapid recurrence of ptosis. This is especially true for larger prostheses placed in the subglandular position. There is an increased risk of nipple malposition because the nipple is moved at the same time as the implant.

Question 135

A 34-year-old woman comes to the office for consultation regarding breast augmentation. She is 5 ft 2 in tall and wears a size 34A brassiere. Submuscular implantation of 300-ml prostheses is planned. She asks for information about silicone versus saline implants. The primary advantage of using saline-filled implants is which of the following? (A) Easier detection of rupture (B) Increased softness (C) Less capsular contracture (D) Less leakage (E) Less wrinkling

Answer 135

The correct response is Option A. Although both silicone and saline implants will rupture eventually, a saline rupture is more easily detected because the saline is resorbed into the body. The breast will be smaller in volume with prominent wrinkling. A ruptured silicone implant retains its volume and is more difficult to detect. Subtle changes, such as decreased upper pole fullness or increased softness, may be the only clues to silicone implant rupture on physical examination. Ultrasonography or MRI may be needed to make the diagnosis. Saline implants are firmer than silicone and are more likely to be palpable than silicone implants. Saline implants are easier to place because they can be inflated after placement and are placed through narrow long tunnels if warranted. Neither implant has been associated with systemic immune syndromes, and both implants produce contractures, wrinkling, and leakage at similar rates.

Question 136

A 55-year-old woman has nipples located 8 cm inferior to the inframammary fold and at the lowest point of the breast contour. Which of the following best describes the degree of breast ptosis in this patient? (A) Glandular ptosis (B) Grade 1 (C) Grade 2 (D) Grade 3 (E) Pseudoptosis

Answer 136

The correct response is Option D. Ptosis is often graded on a scale of 1 to 3. Grade 1 ptosis exists when the nipple is at or above the level of the inframammary fold. Grade 2 ptosis exists when the nipple is below the level of the inframammary fold but not at the lowest point of the breast contour. Grade 3 ptosis exists when the nipple is at the lowest point of the breast contour. Pseudoptosis and glandular ptosis describe similar states in which the nipple is at or near the level of the inframammary fold, but there is breast tissue and a skin envelope that descends or hangs below the level of the inframammary fold.

Question 137

A 30-year-old woman undergoes augmentation mammaplasty with silicone gel prostheses. During the procedure, smooth prostheses are positioned subglandularly. The subglandular placement increases this patient=s risk of which of the following complications? (A) Capsular contracture (B) Double-bubble appearance (C) Infection of the implant (D) Rippling of the implant (E) Rupture of the implant

Answer 137

The correct response is Option A. Capsular contracture remains one of the main drawbacks to the use of silicone breast prostheses. Submuscular placement is a well-established method of reducing the rate of contracture. The introduction of implant-surface texturing in the late 1980s has greatly reduced the contracture rate for prostheses placed subglandularly. Development of capsular contracture is clearly more common in the first two years after subglandular implantation, regardless of the implant type. The large difference in the rate of contracture between textured and smooth prostheses in the subglandular position seems to be negligible in subpectoral placement; both types of implant have low contracture rates. The causes of capsular contracture and the effect of surface texturing and implant position in reducing its incidence are still not clear. Capsule formation is a normal response to the introduction of foreign material and, like most physiologic responses, varies by degree and timing. Additionally, there are general patient factors and local breast factors. The literature suggests that capsule response may be altered by other factors such as infection, diffusion of silicone gel, and smoking. The introduction of surface texturing alters the capsule response. Texturing may produce a more disorganized collagen pattern in the capsule. It has been suggested that subpectoral prostheses have a lower rate of capsular contracture, regardless of surface texturing, because of the massaging action of the overlying pectoralis major.

Question 138

In implantation of saline breast prostheses, which of the following fill levels is most likely to result in rupture due to fold flaw? (A) Above the manufacturer’s recommended maximum (B) Below the manufacturer’s recommended minimum (C) Between the manufacturer’s recommended minimum and maximum (D) Manufacturer’s recommended maximum (E) Manufacturer’s recommended minimum

Answer 138

The correct response is Option B. Based on engineering principles, studies have shown that implant longevity requires an adequate fill level to decrease fold-flaw failures and premature failures that result from underfilling (filling at or below the manufacturer’s recommended minimum level). They have also shown that filling the implants to their least-wrinkled fill level increases implant longevity and decreases premature failure. This generally requires overfilling exceeding the manufacturer’s recommended maximum level. At lower fill levels, implants are softer and more sloping in contour but tend to wrinkle more and have a demonstrably shorter life span because of stress caused by wrinkling. As implant volume increases, palpable and visible wrinkling decreases and longevity increases.

Question 139

A healthy 24-year-old woman undergoes bilateral cosmetic breast augmentation with subglandular saline implants. Which of the following percentages best represents this patient’s 10-year risk for reoperation because of an implant-related indication? (A) 5% (B) 25% (C) 50% (D) 75% (E) 95%

Answer 139

The correct response is Option B. After breast augmentation with saline implants, the 10-year risk for reoperation for any implant-related indication is about 25%. Implant-related indications include deflation of the implant, capsular contracture, hematoma, wound infection, and seroma. In one multicenter retrospective study of 450 patients with a mean follow-up period of 13 years, the reoperation rate for implant-related indications was 25.8%. In another multicenter retrospective study of 504 patients with a mean follow-up period of 6 years, the rate was 21%. In a third retrospective study of 749 women with a mean follow-up period of 5 years, the rate was 12% for cosmetic breast augmentations and 34% for breast reconstructions.

Question 140

A woman comes to the office for consultation regarding explantation of breast prostheses without replacement. In this patient, which of the following quantifications best determines whether mastopexy will be needed in addition to removal of the prostheses? (A) Amount of breast tissue overlying the prostheses (B) Degree of preoperative ptosis (C) Position of the prostheses (D) Size of the areolae (E) Type of implants

Answer 140

The correct response is Option B. The degree of preoperative breast ptosis is the most important factor in determining whether a patient will need mastopexy after explantation of breast protheses. Because breast ptosis remains relatively unchanged or worsens postoperatively, patients with grade II or III ptosis are excellent candidates for breast contouring procedures. The amount of breast tissue overlying the prostheses determines the safety of a breast contouring procedure done simultaneously with explantation. In general, at least 4 cm of breast tissue should be present to allow for adequate vascularity of the skin and separated glandular-nipple flap used for breast contouring, as assessed by the superior and inferior “breast pinch” test. Important factors in determining the type of mastopexy after explantation include the position of the prostheses, the size of the areolae, and the type of implants. For example, if the areolae exceed 50 mm, circumareolar mastopexy is an option.

Question 141

=A 32-year-old woman is undergoing breast augmentation. Which of the following antibiotic solutions is most appropriate for irrigation of the breast pocket? (A) Bacitracin, cefazolin, gentamicin (B) Polymyxin B, gentamicin, cefazolin (C) 10% Povidone-iodine, gentamicin, cefazolin (D) 50% Povidone-iodine

Answer 141

The correct response is Option A. Breast pocket irrigation has been advocated for many years to decrease the incidence of capsular contracture and periprosthetic breast implant infection. Multiple organisms have been cultured around breast implants, and in vitro studies have demonstrated that a combination triple antibiotic (10% povidone-iodine, gentamicin, cefazolin) combination provided improved broad-spectrum activity against the bacteria commonly cultured around breast implants compared with other antibiotic combinations, including polymyxin B, gentamicin, and cephazolin. In 2000, the U.S. Food and Drug Administration approved the premarket application for saline implants; however, contact of the implant with povidone-iodine was stated as a contraindication. Subsequent in-vitro studies examined alternative nonBpovidone-iodine-containing breast pocket irrigation solutions and similar broad-spectrum antibiotic activity was found with the triple combination of bacitracin, cefazolin, and gentamicin. Povidone-iodine (50%) does not provide optimal broad-spectrum activity, and contact of the implant with povidone-iodine is contraindicated. The triple combination of 10% povidone-iodine, gentamicin, and cefazolin is a viable alternative. However, if this combination is to be used, pockets would need to be irrigated clear after its instillation; therefore, this is not the optimal choice. The combination of polymyxin B, gentamicin, and cefazolin has been shown in in-vitro studies to have inferior activity against the common bacteria cultured around breast implants.

Question 142

Compared with traditional (nonendoscopic) transaxillary submuscular techniques for breast augmentation, endoscopic techniques are associated with a decreased risk for which of the following? (A) Capsular contracture (B) Deflation (C) Hypertrophic scarring (D) Infection (E) Malpositioning of the implant

Answer 142

The correct response is Option E. Transaxillary breast augmentation is an established technique that allows the surgeon to make the incision in an aesthetically acceptable area, where it can be hidden. However, one disadvantage of traditional transaxillary augmentation is a lack of visualization of the implant pocket, necessitating blind, blunt dissection at the origin of the pectoral muscle. This limitation may result in improper implant placement, leading to malpositioning of the implant and poor aesthetic results in some patients. In contrast, endoscopic transaxillary augmentation allows the surgeon to divide the origin of the pectoral muscle under direct visualization, thereby effectively lowering the inframammary crease. Endoscopic techniques have not been shown to significantly decrease the incidence of capsular contracture, hypertrophic scarring, or infection. The method of pocket dissection has no effect on the rate of deflation.

Question 143

Elongation and laxity of which of the following structures are most likely to result in breast ptosis? (A) Clavipectoral fascia (B) Cooper’s ligaments (C) Costoclavicular ligaments (D) Superficial fascia of the breast (E) Superficial fascia of the pectoralis muscle

Answer 143

The correct response is Option B. Patients with breast ptosis have drooping of the breast parenchyma, skin, and/or nipple-areola complex occurring as a result of aging, pregnancy, lactation, or weight loss. Anatomically, ptosis is caused by disruption or elongation of Cooper’s ligaments, which are fibrous projections that arise from the breast tissue and fuse with the superficial fascia and dermis of the breast. These ligaments attach the breast parenchyma to the overlying skin. Tumors can stretch these ligaments and cause dimpling and retraction of the skin. Several mastopexy techniques have used absorbable meshes, deep anchoring sutures, or crossing parenchymal slings in an attempt to recreate the tight Cooper’s ligaments and thus correct the ptosis. However, scarring and recurrence of ptosis are frequent complications. The clavipectoral fascia covers the axilla and pectoralis minor muscle; this layer is encountered during axillary dissection. The costoclavicular ligaments anchor the clavicle to the chest beneath the medial superior pole of the breast, but do not enter the breast parenchyma. The superficial fascia of the breast is a filmy, white layer of connective tissue located 2 to 15 mm deep to the skin. The deep layer of the superficial fascia envelopes the breast posteriorly. A loose areolar plane is present between the superficial fascia of the breast and the deep fascia of the pectoralis muscle, and facilitates removal of the breast from the pectoralis muscle during mastectomy. The superficial fascia of the pectoralis muscle covers the muscle but does not extend into the breast.

Question 144

In women undergoing augmentation mammaplasty with saline-filled implants, which of the following techniques is most likely to decrease the longevity of the implant and lead to early rupture? (A) Underfilling of the implants below the manufacturer’s recommended minimum (B) Filling of the implants to the manufacturer’s recommended minimum (C) Filling of the implants to the volume between the manufacturer’s recommended minimum and maximum (D) Filling of the implants to the manufacturer’s recommended maximum (E) Overfilling of the implants above the manufacturer’s recommended maximum

Answer 144

The correct response is Option A. Adequate fill volume is recommended to increase the longevity of a breast implant. This decreases both fold-flaw failure and the potential for premature failure resulting from filling the implant at or below the manufacturer’s minimum volume. Implants are softer and more sloping at lower levels of fill volume, but these “underfilled” implants have also been shown to wrinkle more, leading to a shorter lifespan because of stresses induced by wrinkling. As the volume of the implant increases, palpable and visible wrinkling decreases, resulting in increased longevity. Some studies have also shown that implant longevity can be maximized by filling the implants to the volume at which they exhibit the least wrinkles, even if it exceeds the manufacturer’s maximum recommended volume. However, this technique, known as “overfill,” is not recommended.

Question 145

Which of the following techniques is indicated to preserve sensation to the nipple-areola complex in a patient undergoing augmentation mammaplasty? (A) Avoiding periareolar incisions (B) Avoiding sharp dissection near the clavicle (C) Identifying and tagging of the sensory nerves as they exit the fascia (D) Performing blunt dissection lateral to the lateral edge of the pectoralis muscle (E) Positioning the implant subpectorally

Answer 145

The correct response is Option D. Performing blunt dissection lateral to the lateral edge of the pectoralis muscle only is indicated to preserve sensation to the nipple-areola complex. The fourth and fifth anterolateral intercostal nerves primarily supply sensation to the nipple-areola complex; these nerves perforate the fascia just lateral to the pectoralis muscle through the interdigitation of the serratus anterior muscle. By performing blunt dissection only lateral to the pectoralis muscle, these nerves are stretched but not cut. Although the stretching of sensory nerves may still result in loss of sensation, it is more likely to be temporary than if the nerves are cut sharply. Periareolar incisions do not disrupt the sensory innervation to the nipple-areola complex. It is not necessary to identify and tag the sensory nerves as they exit the fascia. The positioning of the implant (whether subpectoral or subglandular) and the type of dissection performed in the superior aspect of the pocket also will not affect sensation.

Question 146

In a 50-year-old woman who underwent augmentation mammaplasty with silicone implants 12 years ago, a silicone granuloma is noted in the axillary region on clinical examination. Which of the following statements best characterizes this finding? (A) Silicone granulomas are a frequent complication following augmentation mammaplasty or reconstruction with silicone implants (B) Silicone granulomas indicate a link to the existence of implant-related systemic disease (C) Silicone granulomas represent a common tissue response to foreign materials (D) Surgical resection is rarely indicated

Answer 146

The correct response is Option C. Although silicone granulomas are a well-recognized tissue response to the presence of foreign material, such as silicone, these granulomas are found only rarely in patients who have undergone augmentation mammaplasty or reconstruction with silicone gel breast implants. Any granulomas that are detected should be resected if they are symptomatic or of diagnostic concern. No evidence has been presented in peer-reviewed scientific literature to support the theory that silicone granulomas help to cause implant-related systemic disease, and in fact the existence of implant-related systemic disease is controversial in itself.

Question 147

In patients with polymastia, accessory mammary structures are most frequently found at which of the following sites? (A) Neck (B) Axilla (C) Thigh (D) Buttock (E) Vulva

Answer 147

The correct response is Option B. Accessory mammary structures are found along the embryonic milk line, which forms on the ventrolateral body wall from the axilla to the groin. These include most supernumerary breasts, which are most often found in the axilla, just above or below the normal breast, or in the groin. True accessory mammary structures occur less frequently in the inner surfaces of the upper arm and inner side of the thigh or the vulva. Ectopic mammary structures are found outside of the embryonic milk line and represent either true ectopia or displacement of the milk line. Ectopic breast tissue has been reported in the midline and on the face, ear, neck, back, buttock, and outer thigh.

Question 148

Which of the following factors is most critical in determining the need for breast contouring following removal of breast implants? (A) Age of the patient (B) Amount of breast tissue overlying the implant (C) Degree of preoperative ptosis (D) Size of the areola (E) Size and position of the implant

Answer 148

The correct response is Option C. The degree of ptosis seen preoperatively is most important in determining the need for breast contouring following explantation. Because ptosis remains relatively unchanged following implant removal, contouring should be considered in women who have ptosis that is classified preoperatively as grade II or III. The thickness of residual breast parenchyma best determines the viability of performing breast contouring concomitantly with explantation. The breast tissue should have a minimum thickness of 4 cm to allow for vascularity of the overlying skin and of the separated glandular-nipple flap. This is best assessed by performing a breast pinch test superiorly and inferiorly. In determining the type of mastopexy that is most appropriate for each patient undergoing explantation, the elasticity of the skin, size and positioning of the implant, and size of the areola should be assessed. Circumareolar mastopexy is an option in women with areolae that are larger than 50 mm.

Question 149

Which of the following findings is most likely in a patient with Poland syndrome? (A) Anomalies of the feet (B) Bilateral abnormalities of the ribs (C) Breast hypertrophy (D) Hypoplasia of the pectoralis major muscle (E) Polythelia

Answer 149

The correct response is Option D. Poland syndrome is a congenital anomaly that is characterized by unilateral aplasia or hypoplasia of the pectoralis major muscle and adjacent musculoskeletal components. Chest wall anomalies can also be unilateral and include aplasia or hypoplasia of the breast or nipple, partial agenesis of the ribs and sternum, and anomalies of the shoulder girdle. Ipsilateral hand anomalies are common. In severe forms of the disease, the pectoralis, latissimus, and serratus muscles are completely absent. Poland syndrome typically occurs sporadically and its etiology is not fully understood. Men and women are affected equally. Despite the absence of structures of the chest wall, patients have minimal physical disability. Appropriate reconstructive options include transfer of the latissimus in men and women, with the addition of submuscular augmentation mammaplasty in women.

Question 150

In a patient with breast implants, each of the following has been shown to interfere with screening mammography EXCEPT (A) Baker III capsular contracture (B) implant location (C) implant size (D) native breast volume

Answer 150

The correct response is Option C. Several factors have been shown to affect the findings on mammography in women with breast implants. The positioning of the implant and the degree of associated capsular contracture have been known to influence the quantity of breast tissue that can be visualized. In addition, one study showed an increase in the amount of tissue that can be visualized postoperatively in a subset of women with small native breast volume. Therefore, it is important for patients who have breast implants to undergo mammographic evaluation at specialized centers experienced at obtaining mammograms using either compression or displacement (Eklund) techniques, which maximize visualization of the breast parenchyma. The size of the implant has not been shown to affect the amount of breast tissue that can be visualized on mammography.

Question 151

In order to make the diagnosis of Poland's syndrome, which of the following findings must be present? (A) Absence of the nipple (B) Absence of the sternal head of the pectoralis major muscle (C) Brachysyndactyly (D) Hypoplasia of the latissimus dorsi muscle (E) Skeletal abnormalities of the chest wall

Answer 151

The correct response is Option B. All patients diagnosed with Poland's syndrome, a congenital abnormality associated with unilateral findings, have absence of the sternal head of the pectoralis major muscle on the affected side. Some patients with Poland's syndrome have absence of the entire muscle, hypoplasia or absence of the latissimus dorsi or serratus muscles, and/or complete absence of the breast. Other chest wall anomalies also occur unilaterally and can include axillary banding, aplasia or hypoplasia of the nipple, and hypoplasia of the scapula or ribs. Brachysyndactyly of the ipsilateral upper extremity is seen in some patients.

Question 152

A 24-year-old woman has worsening pain and swelling of the right breast 24 hours after undergoing subpectoral augmentation mammaplasty with smooth, round saline-filled implants. On physical examination, the right breast appears significantly larger and is more firm to palpation than the left breast. There are no signs of erythema or ecchymosis. Which of the following is the most appropriate next step in management? (A) Observation (B) Application of an external compression bandage (C) Percutaneous needle aspiration (D) Ultrasound-guided drainage (E) Surgical exploration

Answer 152

The correct response is Option E. This patient has findings consistent with a hematoma, which has been shown to develop in 1% to 3% of patients who have undergone breast augmentation. Hematomas can be seen as late as 14 days postoperatively. The most appropriate next step in management is prompt surgical exploration to evacuate the hematoma and ensure careful hemostasis. The implant can be replaced if there is no evidence of infection; the contralateral implant should only be removed if it is affected. Observation or application of an external compression bandage will only delay the diagnosis and increase the risk for infection or development of capsular contracture. Percutaneous needle aspiration or ultrasound-guided drainage will not completely evacuate the hematoma and will increase the risk for implant perforation.

Question 153

Prior to breast augmentation, management of milky discharge in a regularly menstruating woman should include which of the following? (A) Observation (B) Massage (C) Measurement of serum prolactin level (D) Administration of antibiotics (E) Ovarian biopsy

Answer 153

The correct response is Option C. Although breast discharge is rare in regularly menstruating women who have never been pregnant, it has been shown to occur in 25% of women who have been pregnant in the past. Complete evaluation of galactorrhea should include measurement of the serum level of prolactin (a lactogenic hormone required for milk production), thyroid function studies to rule out hypothyroidism, and a history of all medications, as tricyclic antidepressants and fluoxetine have been shown to contribute to breast discharge. Women who have increased serum prolactin levels should then undergo MRI evaluation to rule of the possibility of pituitary tumor. According to a series of four studies involving more than 500 patients with galactorrhea, a pituitary tumor was the underlying cause in 25%; in contrast, 50% of those studied had idiopathic causes. Appropriate management of idiopathic galactorrhea includes administration of bromocriptine to suppress the release of prolactin. Observation is inadequate management because of the risk for pituitary tumor in these patients. Breast massage is not appropriate and will instead maintain or even initiate galactorrhea in women with prior pregnancies. Because galactorrhea is not associated with infection, antibiotics should not be administered; however, if the discharge is bloody or has brown or green discoloration, the patient should be evaluated for possible infection or tumor. Ovarian biopsy is only indicated if evaluation shows ovarian pathology.

Question 154

Prior to breast augmentation, management of milky discharge in a regularly menstruating woman should include which of the following? (A) Observation (B) Massage (C) Measurement of serum prolactin level (D) Administration of antibiotics (E) Ovarian biopsy

Answer 154

The correct response is Option C. Although breast discharge is rare in regularly menstruating women who have never been pregnant, it has been shown to occur in 25% of women who have been pregnant in the past. Complete evaluation of galactorrhea should include measurement of the serum level of prolactin (a lactogenic hormone required for milk production), thyroid function studies to rule out hypothyroidism, and a history of all medications, as tricyclic antidepressants and fluoxetine have been shown to contribute to breast discharge. Women who have increased serum prolactin levels should then undergo MRI evaluation to rule of the possibility of pituitary tumor. According to a series of four studies involving more than 500 patients with galactorrhea, a pituitary tumor was the underlying cause in 25%; in contrast, 50% of those studied had idiopathic causes. Appropriate management of idiopathic galactorrhea includes administration of bromocriptine to suppress the release of prolactin. Observation is inadequate management because of the risk for pituitary tumor in these patients. Breast massage is not appropriate and will instead maintain or even initiate galactorrhea in women with prior pregnancies. Because galactorrhea is not associated with infection, antibiotics should not be administered; however, if the discharge is bloody or has brown or green discoloration, the patient should be evaluated for possible infection or tumor. Ovarian biopsy is only indicated if evaluation shows ovarian pathology.

Question 155

Which of the following is the most common complication of periareolar mastopexy? (A) Dehiscence (B) Excessive breast projection (C) Nipple discharge (D) Recurrent ptosis (E) Widening of the areola

Answer 155

The correct response is Option E. Widening of the areola is the most common complication following periareolar mastopexy. Techniques developed to minimize the occurrence of areolar dilation include the use of nonresorbable purse-string sutures and creation of an excessively small areola at the time of surgery to compensate for postoperative widening. Less common complications include dehiscence and recurrent ptosis. Excessive projection is rarely seen with periareolar mastopexy; flattened or globular breast shapes are more commonly reported. Nipple discharge is not associated with mastopexy.

Question 156

A 21-year-old woman desires surgical correction because her left breast has an abnormal appearance. On examination, the diameter of the left breast is more narrow at the base than at the midportion, and there is superior displacement of the inframammary fold. The areola is disproportionally enlarged, and the breast tissue appears to be herniating into the areola. The left cup size of her bra is 32B, and the right cup size is 32C. The right breast is normal. Which of the following is the most appropriate management? (A) Right-sided vertical breast reduction (B) Pedicled TRAM flap reconstruction of the left breast (C) Wise-pattern breast reduction on the right with lowering of the inframammary fold (D) Augmentation mammaplasty on the left using a saline-filled implant (E) Augmentation mammaplasty on the left with radial scoring and areolar reduction

Answer 156

The correct response is Option E. This patient has a tuberous, or constricted, breast deformity. Affected patients have unilateral narrowing of the breast; the breast tissue appears to be herniating into the areola. In order to adequately correct this deformity, implant augmentation mammaplasty should be combined with repositioning of the inframammary fold, radial scoring of the breast parenchyma, and reduction of the herniated tissue and areola. This will correct the size and shape discrepancies, resulting in a left breast that appears similar to the unaffected right breast. The right breast should not be reduced by any method to match the size and shape of the abnormal left breast. TRAM flap reconstruction is associated with significantly higher morbidity and should not be performed as initial management. Implantation alone will enlarge the left breast but will not correct the abnormal shape of the breast.

Question 157

In a 21-year-old woman considering augmentation mammaplasty with saline-filled implants, which of the following is appropriate advice concerning potential complications of the procedure? (A) Breast implants do not affect mammographic visualization of all breast tissue (B) Capsular contracture requiring revision occurs in 2% of patients (C) Infection is more common than hematoma (D) Revision procedures are performed in 25% of patients within the first 10 years (E) The risk for deflation is approximately 10% annually

Answer 157

The correct response is Option D. Potential complications of augmentation mammaplasty include the development of infection, deflation of the implant, capsular contracture, breast asymmetry, and visible rippling in patients who have saline implants. One study of 884 women who underwent augmentation mammaplasty reported that 31% developed implant changes, leakage, or capsulotomy; another study of 450 mammaplasty patients showed that approximately 25% underwent at least one additional procedure during the 13-year follow-up period. Because parturition, aging, and weight gain or loss typically result in changes in the breast parenchyma, it is likely that the appearance of the implants will also change over time and that further surgery will be required. Even though specialized views are required for mammography screening in patients with breast implants, it is estimated that approximately 5% of the breast parenchyma is not fully visible on a mammogram. The two studies described above reported rates of significant capsular contracture ranging from 20% to 25%. Hematoma occurred in 3% of implant patients, but only 1% of patients developed infection. Deflation occurred in 1% of patients annually.

Question 158

A 24-year-old woman comes to the office for consultation regarding surgical correction of the breast deformity shown above. Which of the following is the most appropriate management? (A) Augmentation with Wise-pattern mastopexy of both breasts (B) Augmentation with periareolar mastopexy of both breasts (C) Latissimus dorsi myocutaneous flap reconstruction of the left breast and periareolar mastopexy of the right breast (D) Extended dorsi myocutaneous flap reconstruction of the left breast and periareolar reduction of the right breast (E) Transaxillary augmentation of the left breast and periareolar mastopexy of the right breast

Answer 158

The correct response is Option B. The patient described has tuberous breast deformity, which is characterized by three components: herniation of the breast tissue into the nipple-areola complex with a cylindrical projection accompanied by a relatively large areola; deficiency of the lower pole of the breast in both vertical and horizontal axes; and hypoplasia. Periareolar mastopexy with augmentation will give access for radial-releasing incisions, which will allow expansion of the base of the breast and simultaneous areolar reduction. Wise-pattern mastopexy is indicated for more severe breast ptosis. Reconstruction with latissimus flap is a form of treatment for congenital chest wall deformities such as Poland syndrome. Contralateral reduction will not address the tuberous deformity problem. Transaxillary augmentation of the breast will not correct the nipple-areola complex or the constricted base.

Question 159

Which of the following is the most common cutaneous branching pattern of the fourth intercostal nerve as it supplies innervation to the nipple-areola complex? (A) Anterior (B) Central (C) Inferior (D) Lateral (E) Superior

Answer 159

The correct response is Option D. The anterior and lateral cutaneous branches of the third, fourth, and fifth intercostal nerves supply the primary innervation to the nipple-areola complex; the fourth lateral cutaneous branch and third and fourth anterior cutaneous branches provide innervation most consistently. The anterior cutaneous branches course superficially within the subcutaneous tissue and terminate at the medial areolar border. In 93% of patients undergoing breast surgery, the lateral cutaneous branches coursed deeply within the pectoral fascia and reached the nipple from its posterior surface. In contrast, 7% of patients undergoing breast dissection had lateral cutaneous branches coursing superficially within the subcutaneous fat, reaching the nipple from its lateral side. Anatomic studies of the intercostal nerves have failed to identify any central, inferior, or superior cutaneous branches to the nipple-areola complex.

Question 160

Which of the following proteins has been implicated in the pathogenesis of breast implant capsule formation? (A) Albumin (B) Fibrinogen (C) Complement (D) IgG

Answer 160

The correct response is Option B. The surface-bound protein fibrinogen has been implicated in the generation of inflammatory responses to biomaterials (ie, implants); early protein absorption of these biomaterials mediates the foreign body response. Understanding the intricate pathways that result in fibrinogen absorption and its subsequent inflammatory response, leading to capsule formation, may aid in the prevention and management of breast implant capsular contracture. Other dominant proteins in the body, such as albumin, complement, and immunoglobulin G (IgG), have not been shown to play a critical role in capsule formation resulting from foreign body reaction.

Question 161

Which of the following is most characteristic of an in vivo subglandular breast implant that was placed 10 years ago? (A) Changes in the implant shell that may interfere with mammography (B) Easier palpability resulting from increased stiffness of the implant shell (C) Increased potential for the development of immune-related disorders (D) Invasion of the implant shell by surrounding periprosthetic capsular tissue (E) Loss of biomechanical shell strength when compared with preimplantation levels

Answer 161

The correct response is Option E. In a patient who underwent in vivo subglandular breast implantation 10 years ago, a loss of biomechanical strength of the implant shell, when compared with preimplantation levels, is most likely to be identified. Because the implant shell is composed of a vulcanized silicone elastomer, its mechanical strength has been shown to weaken over time following implantation. This weakening, which may result from various factors such as lipid infiltration of the silicone elastomer, has been linked to aging and rupture of the implant. Any changes that occur in the implant shell will not interfere with mammography or with the palpability of the implant. However, other complications, such as capsular contracture, will affect the findings seen on mammography. Therefore, it is important for patients who have breast implants to undergo mammographic evaluation at specialized centers experienced at obtaining mammograms using the displacement (Eklund) technique, which maximizes visualization of the breast parenchyma. The stiffness of the implant shell does not change with time. In the same way, the incidence of immune-related disorders remains steady over the duration of implantation, at one in 40,000 patients. Infiltration of the implant shell by the surrounding capsule has not been demonstrated or implicated in the rupture of aging implants.

Question 162

Silicone polymers are important biomaterials because they have which of the following characteristics? (A) Biological inertness (B) Hydrophilic nature (C) Impermeability (D) Resistance to contamination in the manufacturing process

Answer 162

The correct response is Option A. Silicones such as polydimethylsiloxane are widely used materials for implantation because of their biocompatibility or biological inertness. These polymers are based on the element silicon and are often used as oils, elastomers, and gels. Because silicones are hydrophobic, not hydrophilic, water is repelled and the implanted materials will therefore not interact with enzymes or chemicals within the body. Silicone polymers are semipermeable materials often used in drug delivery systems. Because these materials have relatively poor tensile strength, strict standards are imposed during the production of medical-grade silicone because of the propensity for contamination.

Question 163

A 36-year-old woman is being evaluated 17 years after undergoing augmentation mammaplasty with silicone gel implants. On examination, the implants are soft and minimally palpable; she reports no complications. This patient is at risk for which of the following? (A) Implant rupture (B) Increased silicon levels in breast milk (C) Rheumatoid arthritis (D) Scleroderma (E) Silicone synovitis

Answer 163

The correct response is Option A. This 36-year-old woman is at risk for implant rupture, which has been shown in recent studies to increase proportionately with the age of the implant. One retrospective study determined the mean age of implant rupture to be 13.4 years. MRI is most effective for assessing potential implant rupture, which in one study was reported in as many as 71% of implant patients. Another study showed that 50% of patients who had had implants for seven to 10 years showed evidence of rupture or hemorrhage on MRI. Although attempts have been made to associate silicone gel implants to the onset of rheumatoid symptoms in children who were breast-fed, one study showed no difference in silicone levels measured in breast milk in women with implants versus controls. In addition, several large epidemiologic studies have shown no link between silicone gel implants and the subsequent development of either rheumatologic (ie, rheumatoid arthritis) or connective tissue (ie, scleroderma) diseases. Silicone synovitis occurs in patients who have silicone joint prostheses, but not in patients with silicone gel breast implants.

Question 164

A 25-year-old woman who smokes cigarettes undergoes bilateral explantation of ruptured breast implants. On preoperative examination, she has severe ptosis with breast thickness of less than 4 cm; the nipple-areolar complex is positioned 5 cm below the inframammary crease. Which of the following surgical procedures would most effectively re-establish aesthetic breast contour? (A) Delayed mastopexy (B) Inframammary fold wedge excision (C) Periareolar mastopexy (D) Modified Kiel (vertical) mastopexy (E) Wise pattern mastopexy

Answer 164

The correct response is Option A. In this patient who has just undergone explantation of ruptured bilateral breast implants, the aesthetic contour of the breast will be best re-established with a mastopexy procedure that is delayed for at least three months following the explantation. Indications for this procedure include severe ptosis requiring nipple elevation of 4 cm, a breast mound smaller than 4 cm, and a significant history of smoking. Because this patient has many risk factors and moderate ptosis, requiring 2 cm to 4 cm of nipple repositioning, a two-stage procedure is recommended to reduce the risk for potential complications, including skin loss or compromise of the nipple-areolar complex. Simultaneous breast contouring procedures should be avoided in these patients. The initial stage involves explantation and capsulectomy using an inframammary approach; elective mastopexy is then performed three months later. Inframammary fold wedge excision is recommended for patients with pseudoptosis. This is defined as adequate breast volume and positioning of the nipple above the inframammary crease with a nipple-to-inframammary crease distance of greater than 6 cm. The wedge excision technique involves transposition of the inferior dermal parenchymal flap in order to increase breast projection. For patients who have grade I ptosis, a tension-free periareolar mastopexy can be performed to reposition the nipple if it lies more than 2 cm below the inframammary fold and has a diameter of less than 50 mm. In contrast, if the diameter is greater than 50 mm and more than 2 cm of repositioning is required, a modified Kiel (vertical) mastopexy is recommended instead. Patients with moderate grade II ptosis who require repositioning of 2 cm to 4 cm should undergo Wise pattern or a similar type of mastopexy.

Question 165

Which of the following findings are consistent with tuberous breast syndrome? (A) Deficiency of the skin envelope, a decrease in vertical breast height, breast hypoplasia, and absence of the pectoralis major muscle (B) Deficiency of the skin envelope, a decrease in vertical breast height, breast hypoplasia, and areolar hypertrophy (C) Deficiency of the skin envelope, elongation of vertical breast height, breast hypertrophy, and absence of the pectoralis major muscle (D) Redundancy of the skin envelope, a decrease in vertical breast height, breast hyperplasia, and absence of the pectoralis major muscle (E) Redundancy of the skin envelope, elongation of vertical breast height, breast hyperplasia, and areolar hypertrophy

Answer 165

The correct response is Option B. Tuberous breast syndrome, also referred to as tubular breast syndrome or constricted breast syndrome, is comprised of a broad spectrum of features. Patients with tuberous breast syndrome may have any or all of several findings. These can include a deficiency in the skin envelope that can involve only one quadrant or can lead to severe constriction, a decrease in the overall vertical height from the top of the breast to the inframammary fold, hypertrophy of the areola, which is believed to compensate for constriction at the base of the breast, and a true deficit of breast tissue, particularly at the area of skin deficiency. After the skin is released surgically, volume must be added to create a normal-appearing breast. Absence of the pectoralis major muscle is a feature of Poland's syndrome.

Question 166

A 45-year-old woman who underwent bilateral augmentation mammaplasty with silicone gel implants 20 years ago has developed capsular contracture involving one of her implants. She is concerned about the integrity of the implants. Ultrasonography suggests intracapsular rupture of the implant. Which of the following is the most appropriate next step in management? (A) Observation (B) Level-two ultrasonography (C) Mammography (D) MRI (E) Surgery

Answer 166

The correct response is Option E. This patient who has probable intracapsular rupture of one of her 20-year-old silicone gel implants requires surgery to remove the ruptured implant and periprosthetic capsule. Test characteristics (sensitivity and specificity) and implant rupture prevalence have been used to calculate the probability of rupture for various patient scenarios. In asymptomatic patients, the pretest rupture prevalence is estimated at 6.5%. Ultrasonography should be used as an initial diagnostic test because of its relatively low cost. If screening ultrasonography shows no rupture, the probability of rupture drops to 2.2%. No further work-up is necessary. If ultrasonography suggests rupture, the relatively low probability (37.8%) of true rupture requires a confirmatory test using MRI. In symptomatic patients (ie, patients who have breast asymmetry or capsular contracture), the high prevalence of rupture markedly raises the probability of rupture after positive findings on ultrasonography. In symptomatic patients whose implants are no more than ten years old, the prevalence of rupture is estimated to be 31%. Positive ultrasonography increases the probability of true rupture to 79.7%, and this probability is increased to 97.5% if a follow-up MRI shows rupture. In this woman and other symptomatic patients whose implants are more than ten years old, the high probability of true rupture (94%) after positive findings on ultrasonography obviates the need for any further diagnostic testing such as MRI. Observation is inadequate because implants that are known or suspected to be ruptured should be removed. Mammography is recommended for screening of benign and malignant diseases. However, evaluation of implant status by routine mammography is limited, particularly in cases of intracapsular rupture. Not all of the implant and surrounding breast tissue can be visualized, and patients with severe capsular contracture and painful breasts may not be able to undergo the compressive technique required to execute the study. Only when the silicone has migrated away from the fibrous capsule (extracapsular rupture) can mammography offer accurate diagnosis. Level-two ultrasonography is a diagnostic maneuver used to evaluate a fetus in the obstetrical setting.

Question 167

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

Answer 167

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.

Question 168

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

Answer 168

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.

Question 169

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

Answer 169

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.

Question 170

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

Answer 170

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.

Question 171

A 38-year-old woman comes to the office because of increasing asymmetry between the breasts during the past year. She states that the left breast has become fuller superiorly and increasingly firm. Eight years ago, she underwent dual-plane augmentation mammaplasty with silicone implants. Examination shows that the left breast is larger and firmer than the right. The right breast implant is soft. Photographs are shown. Which of the following is the most appropriate next step in management? A) Capsulectomy B) Mammography C) MRI D) PET-CT scan E) Ultrasonography

Answer 171

The correct response is Option E. This patient has noted an increase in the size of the left breast over the course of the past year. This should raise concerns for late-onset seroma and thus prompt an evaluation to rule out breast implant-associated anaplastic large cell lymphoma (BIA-ALCL). BIA-ALCL is associated with textured implants or patients who have had a textured device in the past. After history and physical examination, the most appropriate next step is ultrasonography of the breast and axilla to evaluate for a mass or effusion around the implant. If fluid is present, fine-needle aspiration should be performed with cytology and flow cytometry. The fluid should be evaluated for CD30 cell surface receptor positivity and anaplastic lymphoma kinase. If breast implant associated-squamous cell carcinoma (BIA-SCC) is present, the fluid would be CK5/6+ and p63+. Flow cytometry would also be positive for squamous cells and keratin.If a mass is seen, a biopsy should be performed. Capsulectomy may play a role in the treatment of this patient. However, first one must determine a diagnosis and whether the findings are related to seroma or other pathology versus a capsular contracture. Mammography may play a role in the future workup of this patient; however, ultrasonography is the recommended first step due to its sensitivity for evaluating effusions. Ultrasonography is a cost-effective test for both diagnosing and sampling periprosthetic fluid, and many plastic surgeons now perform ultrasonography in their office. MRI may be indicated if ultrasonography is inconclusive. A PET-CT scan would be obtained for staging if the diagnosis is confirmed or a high index of suspicion still exists after cytology.  

Question 172

A 23-year-old woman who underwent bilateral augmentation mammaplasty 6 months ago comes to the office because of new onset of firmness of the left breast. On physical examination, the left breast has a normal appearance but is mildly firm on palpation. Which of the following best describes this patient's Baker grade capsular contracture? A) Grade 1 B) Grade 2 C) Grade 3 D) Grade 4

Answer 172

The correct response is Option B. Baker et al classified capsular contracture as follows: * Grade 1: Capsular contracture of the augmented breast feels as soft as an unoperated breast. No firmness on palpation. * Grade 2: Capsular contracture is minimal. The breast is less soft than an unoperated breast. The implant can be palpated but is not visible. * Grade 3: Capsular contracture is moderate. The breast is noticeably firmer. The implant can be palpated easily and is distorted or visible. * Grade 4: Capsular contracture is severe. The breast is hard, tender, and painful with significant distortion present. The capsule thickness is not directly proportional to palpable firmness, although some relationship may exist.  

Question 173

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

Answer 173

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.

Question 174

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

Answer 174

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.

Question 175

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

Answer 175

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.

Question 176

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

Answer 176

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.

Question 177

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

Answer 177

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.