Breast Augmentation, Mastopexy Flashcards
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
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 outcomes.
2018
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
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.
2018
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
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.
2018
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
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
2018
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
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.
2018
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
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.
2018
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
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.
2018
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
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.
2018
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
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.
2018
A 58-year-old woman undergoes removal of round 280-cc silicone gel implants she has had for over 30 years. New silicone gel implants measuring 10 cm in width by 12 cm in height with a 5-cm projection are placed. Compared with her original gel implants, the new implants are more likely to have a higher rate of which of the following complications?
A) Contracture
B) Infection
C) Rippling
D) Rotation
E) Rupture
The correct response is Option D.
Breast implant technology has evolved greatly since implants were introduced in the 1960s. Increased cross-linking of silicone polymers (polydimethylsiloxanes) results in a more stable, cohesive form and closer shell-gel interactions. Advantages of these more “form-stable” implants include lower rates of rippling and rupture. They allow for the creation of shaped implants that offer clear advantages for certain patients, such as those seeking a natural upper pole shape transition, and those with wider or taller breast shapes.
The biggest drawback of shaped implants is the need to place them in a precise surgical pocket lest they rotate, causing deformity and potentially requiring reoperation. As long as surgeons follow sound surgical principles of dissecting an appropriate pocket limited to the approximate width of the implant, malrotation rates are low, typically in the 1.5% range. In one study, half of patients with implant rotation improved with manual repositioning and taping for 3 to 6 weeks, while the other half required reoperation.
Infection rates do not vary among implant types.
Shaped implants have textured shells, which have been shown to have lower rates of capsule contracture, particularly in the subglandular position.
Implant rupture rates are also lower in new generation implants, in the 0.7% per year range.
Visible rippling rates are more common in thinner consistency implants, such as saline and older silicone devices.
2017
Breast implant–associated anaplastic large cell lymphoma is most closely associated with which of the following implant characteristics?
A) High-profile dimensions
B) Saline filling
C) Silicone gel filling
D) Smooth shell
E) Textured shell
The correct response is Option E.
The overwhelming majority of reported cases of breast implant–associated anaplastic large cell lymphoma (BIA-ALCL) have been associated with textured surface implants.
Anaplastic large cell lymphoma in association with breast implants is a rare occurrence; however, when it does appear, the course is usually less aggressive with a better prognosis than when it is unrelated to breast implants. Recent studies suggest that the breast implant shell causes a chronic T-cell stimulation. This reaction is thought to be caused by an interaction of textured surface characteristics and associated biofilm.
BIA-ALCL associated with smooth shell implants has occurred; however, it is disproportionately rare.
ALCL is seen with both silicone- and saline-filled implants. These numbers are highly influenced by the specific popularity of each implant. Specific implant dimensions, be it projection or width, are not uniquely associated with ALCL.
2017
Which of the following is the most common cause of litigation in cosmetic breast surgery?
A) Assault
B) Failure to diagnose or treat an injury related to the procedure
C) Lack of informed consent
D) Negligence
E) Retained surgical instrument
The correct response is Option D.
Plastic surgery faces one of the highest proportions of malpractice claims compared with other medical specialties. A number of studies have revealed that breast-related surgeries account for 37% of overall claims against plastic surgeons. The most common cause of action is negligence, related either to lack of appropriate knowledge or skill or to failing to meet the standard of care. The second most common cause of action is lack of informed consent. Lack of informed consent results from the failure of the physician to thoroughly discuss the risks associated with surgery and the options of alternative therapies. Other causes of action include failure to diagnose or treat injury related to the procedure, retained surgical materials, assault, and distortion of physician’s credentials.
2017
An otherwise healthy 28-year-old woman comes to the physician requesting removal of bilateral axillary masses. She states that the masses fluctuate in size and tenderness with her menstrual cycle. She reports that the masses have not had discharge or drainage. Physical examination shows smooth, spongy masses in both axillae. A photograph is shown. Which of the following is the most appropriate next step in management of this patient?
A) Excise the bilateral axillary masses and skin
B) Obtain bilateral mammograms of the axillary masses
C) Order an MRI of the chest
D) Perform a core biopsy of both axillary masses
E) Perform liposuction
The correct response is Option A.
This patient presents with ectopic breast tissue. In utero, the milk line (galactic band) forms at 5 weeks of gestation. This bilateral structure courses from the axillae to the groin, and normal breasts form in the prepectoral region after there has been regression of the rest of the galactic band. When there is failure of this regression, breast tissue remains in locations outside of the normal breast. The most common location for ectopic breast tissue is in the axillae, although it can be found anywhere along the milk line from the axillae to the groin. Ectopic breast tissue outside of the milk line has been described and is termed aberrant breast tissue.
The tissue found in these ectopic locations is breast tissue with the same characteristics and propensity for disease as normally located breast tissue, and breast cancer has been described in these tissues. In the absence of pathologic findings such as a mass, pain, and skin changes that are associated with breast cancer, there is no strong oncologic indication for excision. If there are findings concerning for a neoplasm, then work-up should be initiated and might include further imaging, core biopsy, and surgery. However, most cases present without pathologic findings and are excised to achieve a more reasonable appearance for the patient, the ability to don clothing more comfortably, and for the obvious social advantages.
In this case, the patient is young, has no complaints, and has no physical findings to suggest a neoplasm. Excision should be offered.
Obtaining bilateral mammograms is incorrect because there is no indication for imaging in this patient based on her age, history, and physical examination. In addition, mammograms of axillary breast tissue are technically unfeasible.
Performing a core biopsy is incorrect as there is no concern for malignancy in this case. In the case of a mass noted within the ectopic axillary breast tissue, then an oncologic workup should be initiated which might include a core biopsy.
An MRI of the chest is incorrect because there is no indication for imaging in this patient based on her age, history, and physical examination.
Reassuring the patient with no further action is not the most appropriate management, as it will not address the patient’s concerns and desires. In the patient who does not request excision or is not an appropriate surgical candidate, then reassurance and surveillance are appropriate.
As this is a young female with axillary breast tissue, liposuction will not improve the excess breast tissue or skin.
2017
In embryologic breast development, which of the following best describes the formation of the mammary ridge?
A) Starts at the fifth or sixth week of fetal development, when buds of mesoderm grow into the overlying ectodermal skin layer
B) Starts at the fifth or sixth week of fetal development, when outgrowths from the ectodermal skin layer penetrate into the mesoderm
C) Starts at the seventh or eighth week of fetal development, when buds of mesoderm grow into the overlying ectodermal skin layer
D) Starts at the seventh or eighth week of fetal development, when outgrowths from the ectodermal skin layer penetrate into the mesoderm
E) Starts at the third or fourth week of fetal development, when buds of mesoderm grow into the overlying ectodermal skin layer
The correct response is Option B.
Muntan, et al. described breast development as starting at the fifth or sixth week of development, when outgrowths from the ectodermal skin layer penetrate into the underlying mesoderm, forming the mammary ridge or milk line. The ectodermal thickenings along the mammary line regress between gestational months 2 and 4, except for two of them in the region of the third and fourth ribs. The ectoderm keeps on extending into the underlying mesoderm at the fifth month, and a branching network forms what will eventually become the lactiferous system. The supportive connective and adipose tissue of the breast develops from the surrounding mesenchyme.
2017
A 36-year-old woman, gravida 3, para 3, comes to the physician because she desires larger breasts. She has breast-fed three children. Physical examination shows grade 3 ptosis and loss of superior pole volume. The distance from nipple to sternal notch is 26 cm. Result of upper pole pinch test is 1.5 cm. A dual-plane augmentation/mastopexy is planned. Which of the following is the strongest indicator for subpectoral placement of the implant in this patient?
A) Concurrent mastopexy
B) Grade 3 ptosis
C) Loss of superior pole volume
D) Nipple to sternal notch distance of 26 cm
E) Pinch test result of 1.5 cm
The correct response is Option E.
A dual-plane approach is subpectoral in the superior pole and subglandular in the inferior pole. This is to afford more subcutaneous coverage in the superior pole. Tebbetts recommends pinching the skin and subcutaneous tissues of the superior pole for a “pinch test.” For thickness less than 2 cm, he recommends a dual-plane placement for adequate soft tissue coverage. This is not affected by the grade of ptosis, need for mastopexy, history of loss of superior pole volume, or nipple to notch distance.
2017
Which of the following is most commonly associated with decreased incidence of capsular contracture?
A) Formation of biofilm
B) Placement of textured silicone device
C) Subglandular placement of the implant
D) Use of a periareolar incision
E) Use of a postoperative surgical brassiere
The correct response is Option B.
The rest of the options have been shown to increase the incidence of capsular contracture. Textured silicone implants, inframammary incisions, and submuscular implant placement have been shown to decrease the incidence of capsular contracture. The use of a surgical brassiere postoperatively has not been shown to decrease incidence of capsular contracture as well.
2017
In augmentation mammaplasty, which of the following is the ideal upper pole to lower pole anatomic ratio?
A) 25:75
B) 35:65
C) 45:55
D) 50:50
E) 55:45
The correct response is Option C.
Studies have demonstrated the ideal anatomical characteristics of the breast to include: an upward pointing nipple, a straight or mildly concave upper pole slope, smooth lower pole convexity and fuller lower pole compared to upper pole. Breasts with an upper pole-to-lower pole ratio of 45:55 were identified as defining the ideal breast. The ratio was defined ideal by respondents including women, men, plastic surgeons, and individuals of ethnic diversity.
2017
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
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.
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
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.
2017
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
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.
2017
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
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.
2017
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
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.
2017
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
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.
2016
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
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.
2016
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
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.
2016
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
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.
2016
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
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.
2016
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
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.
2016
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
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.
2016
An 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
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.
2016
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
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.
2016
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
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.
2016
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
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.
2016
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
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.
2016
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
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.
2016
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
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.
2015
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
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.
2015
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
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.
2015
