Breast Reconstruction 01-22 Flashcards
An otherwise healthy 45-year-old woman undergoes bilateral breast reconstruction with free deep inferior epigastric perforator-based flaps. Only the medial deep inferior epigastric vein was anastomosed to the medial internal mammary vein using a 3.5-mm venous coupler. Her right breast flap has become increasingly congested. The cutaneous Doppler signals are strong, and examination of the pedicle shows good flow through both arterial and venous anastomoses. There is no kinking or hematoma. Which of the following is the most appropriate next step in management?
A) Additional anastomosis of the lateral deep epigastric vein
B) Additional anastomosis of the superficial inferior epigastric vein
C) Revise the arterial anastomosis
D) Revise both anastomoses
E) Revise the venous anastomosis
The correct response is Option B.
The most appropriate next step in management is to supercharge the flap using an additional anastomosis of the superficial inferior epigastric vein. This is a clinical example of persistent superficial venous system dominance. This is due to either the superficial system being the dominant venous drainage of the abdominal wall and the absence of connections between the superficial and deep venous systems, or the lack of an adequate number of perforators in the flap. In either case, the venous blood is not getting from the superficial system into the deep system, which is the egress given that the deep system is the only system anastomosed.
There is no technical issue with the anastomosis or venous thrombosis; therefore, revising the deep anastomoses is not required. Rather, it is an intra-flap venous system issue that requires the superficial system to be drained somehow. This is accomplished by anastomosing the superficial inferior epigastric vein to either the deep system in the flap or to another drainage system in the chest like the intercostal system. It is interesting to note that the two reasons for the above issue (i.e., inadequate perforator selection or anatomic lack of communicating vessels between the superficial and deep system), though distinct entities, clinically present similarly and are treated in the same way. The incidence of venous congestion secondary to persistent superficial system dominance is about 0.9%.
An otherwise healthy 45-year-old woman develops an infection following implant-based breast reconstruction. Which of the following gram-negative species is most likely to be involved with the infection?
A) Enterobacter spp
B) Escherichia coli
C) Proteus spp
D) Pseudomonas spp
E) Staphylococcus spp
The correct response is Option D.
The most likely gram-negative species associated with implant-based breast reconstruction infection is Pseudomonas spp.
In general, gram-positive organisms (about 70%) are most commonly associated with such infections, in which Staphylococcus species are the most commonly cultured (51%). Gram-negative species are associated with about 27% of the infections, of which Pseudomonas were the most commonly cultured. These data guide the empiric antibiotics that should be used initially at presentation. Staphylococcus species are the most common bacteria involved with breast implant infections; however, they are gram-positive bacteria.
An otherwise-healthy 45-year-old woman presents for discussion regarding autologous breast reconstruction following mastectomy. Medical history includes abdominoplasty following the birth of her last child. After examination, the surgeon determines that she is a good candidate for bilateral lumbar artery perforator flaps. During the preoperative discussion, the surgeon compares the risks, benefits, and expected outcomes between lumbar artery perforator flaps and deep inferior epigastric artery perforator (DIEP) flaps, which are the surgeon’s typical initial choice for autologous tissue transfer. Which of the following complications is associated with lumbar artery perforator flaps when compared with DIEP flaps?
A) Higher breast dissatisfaction rate
B) Higher hematoma rate
C) Higher secondary revision rate
D) Higher total flap loss rate
The correct response is Option D.
Lumbar artery perforator (LAP) flaps have recently been shown to be a good autologous breast reconstruction option when deep inferior epigastric perforator (DIEP) flaps are not available. LAPs do carry a higher total flap loss rate with reports of 6.6 to 9% compared with less than 2% for DIEPs. Based on the microvascular compromises, which are reported to be more venous than arterial, the take-back rate on LAPs is also expectantly higher than DIEPs. Hematoma and secondary revision rates are very similar between the two groups. Based on BREAST-Q data, the satisfaction rate in the breast reconstruction is also very similar between the two groups. This is not the case in satisfaction rate of the donor site, where responses were lower in LAPs compared with DIEPs. This is likely due to a higher donor site complication rate in the form of seromas and postoperative pain.
A 56-year-old woman presents with significant capsular contracture and deformity of her left reconstructed breast 3 years after undergoing bilateral mastectomy, left-sided radiation therapy, and subsequent two-stage implant reconstruction. A photograph is shown. She has a history of abdominoplasty. Which of the following is the most reliable way to achieve an acceptable reconstruction in this patient?
A) Conversion to prepectoral plane with acellular dermal allograft
B) Deep inferior epigastric perforator flap
C) Implant exchange with capsulectomy and acellular dermal allograft
D) Implant exchange with capsulotomy
E) Latissimus dorsi flap with expander
The correct response is Option E.
In this patient with a history of left-sided radiation and a severely contracted and deformed implant, the most reliable way to achieve an acceptable reconstruction would be to convert to some form of autologous reconstruction. Given her prior history of abdominoplasty, a deep inferior epigastric perforator flap is not feasible. A latissimus dorsi flap with an expander is a reliable option. Implant exchange with capsulotomy would have an extremely high risk for recurrence of capsular contracture and deformity. Capsulectomy with acellular dermal allograft replacement would have a fairly high risk for complications due to adding yet more foreign body to a radiated tissue bed, and there would still be a high risk for recurrent capsular contracture. Conversion to a prepectoral plane with acellular dermal allograft would have a potentially higher risk for complications because even more foreign body is required to fully wrap the implant.
A 42-year-old woman presents 1 week following exchange of tissue expander for permanent implant, in which skin glue was used for closure. She reports an itchy rash around her incision. Medical history includes right breast cancer, for which she has undergone mastectomy and placement of a pre-pectoral textured tissue expander with acellular dermal allograft coverage. She is afebrile. A photograph is shown. Which of the following is the most likely cause of this rash?
A) Anaplastic large-cell lymphoma infiltration of the skin
B) Antiphospholipid antibody-mediated urticaria
C) Cyanoacrylate exposure and dermatitis
D) Lymphatic disruption leading to red breast syndrome
E) Staphylococcus aureus cellulitis
The correct response is Option C.
The patient has recently had surgery and is doing well except for her skin rash. The rash appears to be localized to the incision. Contact dermatitis to surgical adhesives is a common problem. There is growing recognition that surgical glues containing cyanoacrylate may be associated with a 10 to 15% rate of rashes secondary to Type IV allergic hypersensitivity reactions. These typically appear within 3 to 7 days and are treated by removal of the surgical glue and topical steroid cream. Patients who have previously been exposed to surgical glue are more at risk for developing sensitivity.
Surgical site infection is a concern following implant placement. However, a Staph cellulitis is typically more diffuse and has a different appearance more consistent with erythema rather than a rash. Antiphospholipid syndrome (APS) may be associated with a rash and other systemic symptoms; however, there is no indication within the history that this patient suffers from that condition. Additionally, the timing and location of the rash along the incision point to other local causes rather than APS. Lymphatic disruption is one theory to explain red breast syndrome, which is a condition that has been reported in relation to acellular dermal matrix placement. This is typically more diffuse and usually occurs in the acute setting following acellular dermal matrix placement. Anaplastic large-cell lymphoma is a rare type of cancer that may be associated with breast implants and may present with swelling and a rash. There is a higher rate of this condition in patients who have had textured devices. The mean onset for this condition is 8 years after exposure to the breast implant. This patient’s clinical course is not typical of anaplastic large cell lymphoma.
A 40-year-old woman with cancer of the right breast undergoes a bilateral skin-sparing mastectomy and immediate reconstruction with placement of submuscular tissue expanders. After completion of the bilateral mastectomies, the breast skin flaps appear to be dusky with some bruising of the skin edges. Which of the following pharmacologic agents has been shown to decrease the rate of mastectomy flap necrosis?
A) Indocyanine green
B) Lidocaine with epinephrine
C) Nitroglycerin paste
D) Papaverine
The correct response is Option C.
Nitroglycerin paste has been shown to decrease the rate of mastectomy flap necrosis.
Topical nitroglycerin ointment application has been shown in a prospective randomized clinical trial to decrease the incidence of mastectomy flap necrosis in immediate tissue expander breast reconstruction.
Papaverine is incorrect since it is a vasodilator that relaxes smooth muscles in blood vessels. This agent is useful during microvascular surgery to decrease vasospasm of arteries and veins but has not been used to decrease the rates of mastectomy flap necrosis.
Indocyanine green is incorrect since it is a dye used for diagnostic purposes during fluorescence angiography. It can be administered intravenously and be used to assess tissue perfusion intraoperatively, which can be helpful for diagnosis of mastectomy flap necrosis. It does not change tissue perfusion, however.
Lidocaine with epinephrine is incorrect since it is an analgesic agent with a vasoconstrictor. This can be used intraoperatively for pain control and hemostasis. At more dilute concentrations, it can be used for tumescent injection during mastectomy. This has not been shown to decrease the rates of mastectomy flap necrosis.
A 51-year-old woman with history of right breast invasive ductal carcinoma (IDC) status post right skin-sparing mastectomy, axillary node dissection, and adjuvant radiation therapy presents to discuss delayed breast reconstruction. Her recent positron emission tomography scan was negative for distant metastasis. Her pathology report shows positive estrogen receptor, positive progesterone receptor, negative human epidermal growth factor receptor, and an IDC 2.5 cm in size with three positive axillary lymph nodes. Based on these findings, which of the following is the TNM classification for this tumor?
A) T1 N2 M0
B) T1 N3 M1
C) T2 N1 M0
D) T2 N3 M0
E) T3 N2 M0
The correct response is Option C.
The tumor node metastasis (TNM) classification helps to stage tumors. Based on the information given about this breast cancer patient, she would be staged as T2 (primary tumor is 2.5 cm), N1 (three axillary nodes involved), and M0 (no evidence of metastatic disease on systemic radiologic workup. Please see the TNM classification system below.
Tumor staging: Tx - tumor cannot be assessed; T0 - no evidence of primary tumor; T1 - tumor less than 2 cm; T2 - tumor greater than 2 cm but less than 5 cm; T3 - tumor greater than 5 cm; T4 - tumor with direct extension into chest wall or skin.
Node staging: Nx - nodes cannot be assessed; N0 - no nodal involvement; N1 - one to three ipsilateral nodes involved; N2 - four to nine ipsilateral or internal mammary nodes involved; N3 - ten or more ipsilateral nodes.
Metastasis staging: Mx - distant spread cannot be assessed; M0 - no distant spread; M1 - cancer has spread to distant organs or liver.
A 51-year-old woman presents for breast reconstruction. She was recently diagnosed with left-sided breast implant-associated anaplastic large cell lymphoma (BIA-ALCL). She has bilateral submuscular textured implants that were placed 8 years ago. The patient would also like to have the contralateral implant removed during the left-sided surgery. Which of the following best describes the chance of finding BIA-ALCL pathology in this patient’s contralateral breast?
A) 1.6%
B) 4.6%
C) 7.6%
D) 10.6%
E) 13.6%
The correct response is Option B.
The risk for breast implant-associated anaplastic large cell lymphoma (BIA-ALCL) has been estimated to be between 1:1000 and 1:30,000 women with textured breast implants. Management consists of removal of the implant, complete surgical excision of the surrounding implant capsule, and excision of any suspicious lymph nodes. According to National Comprehensive Cancer Network guidelines, removal of the contralateral implant can be considered because in 4.6% of reported cases, the pathology disclosed BIA-ALCL in the contralateral breast.
Once full diagnostic workup and staging are performed, the options for reconstruction need to be discussed with the patient. A patient with resectable disease, stage IA to stage IC, can be offered resection and immediate reconstruction with either a smooth implant or autologous reconstruction, or the patient can choose to have resection followed by repeat imaging in 3 to 6 months and delayed reconstruction.
Stage IA is T1 N0 M0 disease confined to effusion or a layer on the luminal side of the capsule with no lymph node involvement and no distant spread.
Stage IC is T3 N0 M0 cell aggregates or sheets infiltrating the capsule, no lymph node involvement, and no distant spread.
In advanced disease, stages IIA to IV, surgical resection and chemotherapy followed by repeat positron emission tomography CT scan in 6 to 12 months is recommended. If the patient has no signs of metastatic activity, then delayed reconstruction with either a smooth implant or autologous reconstruction are both options.
A 45-year-old woman presents for bilateral immediate breast reconstruction. An abdominal flap is planned. The patient demands reconstruction with a flap that has the lowest abdominal wall morbidity since she is a yoga and pilates instructor. Which of the following autologous flaps utilized for breast reconstruction results in the lowest rate of abdominal wall morbidity?
A) Deep inferior epigastric perforator flap
B) Free transverse rectus abdominus myocutaneous flap
C) Muscle-sparing free transverse rectus abdominus myocutaneous flap
D) Pedicled transverse rectus abdominus myocutaneous flap
E) Superficial inferior epigastric artery flap
The correct response is Option E.
Of all the abdominally based flaps listed for breast reconstruction, only the superficial inferior epigastric artery (SIEA) flap does not violate the abdominal fascia. Each of the other flaps are associated with abdominal bulge or hernia formation. Pedicled and free transverse rectus abdominus myocutaneous (TRAM) flaps both involve the harvest of significant abdominal muscle and are associated with more abdominal wall dysfunction than with deep inferior epigastric perforator (DIEP) flaps. It is unclear whether there is a difference in abdominal wall morbidity following muscle-sparing free TRAMs versus DIEPs. However, only the SIEA flap offers no muscle dissection or violation of the abdominal fascia.
A 45-year-old woman with a history of breast cancer presents for a discussion of breast reconstruction with silicone breast implants. She inquires about the current screening recommendations for implant rupture. Which of the following postoperative screening recommendations should the surgeon communicate to this patient?
A) CT scan at 3 years followed by CT, MRI, or ultrasound every 2 years thereafter
B) Mammogram every 5 years
C) MRI at 2 years then every 3 years thereafter
D) MRI at 3 years then every 2 years thereafter
E) MRI or ultrasound at 5 to 6 years then every 2 to 3 years thereafter
The correct response is Option E.
As a critically important part of the informed consent process, practitioners should be very familiar with updated information from the FDA. The screening recommendations for implant rupture for women with silicone gel-filled implants were recently updated (September 2020). The current FDA recommendations are that asymptomatic patients should have the implants evaluated with either ultrasound or MRI 5 to 6 years after implantation and then every 2 to 3 years thereafter. This new recommendation replaces the old recommendation by adding ultrasound as an accepted modality and extending the time until the first evaluation. The older recommendation was MRI evaluation at 3 years, with follow-up evaluation being performed every 2 years. These recommendations apply to women who have cosmetic augmentation and breast reconstruction. CT scan is not an acceptable modality for implant evaluation. Since this patient has had mastectomies and breast reconstruction, mammography is not indicated.
Breast cancer cells can spread directly to the cranial cavity and brain via the vertebral venous plexus (Batson plexus). Through which of the following veins is it possible for these cells to reach this plexus?
A) Axillary
B) Azygos
C) Brachiocephalic
D) Intercostal
E) Internal thoracic
The correct response is Option D.
Hematogenous spread through the intercostal veins is the most likely way for breast cancer to reach the internal vertebral venous plexus. Although 75% of the lymph from the breast drains to the axillary nodes with most of the remaining lymph draining to the parasternal nodes, these lymphatic channels are not the most likely way to transmit cancer to the internal vertebral venous plexus. This plexus of veins would be most likely to receive cancer cells transmitted through the blood. The internal thoracic vein drains blood from the breast in the opposite direction of the vertebral column. The thoracoacromial artery supplies blood to the breast, as opposed to draining the breast, and therefore would not provide a route for spreading cancer.
A 56-year-old woman presents with right breast swelling 10 years after undergoing bilateral mastectomy and reconstruction with bilateral submuscular textured implants with an acellular dermal matrix sling. Examination shows right-sided periprosthetic fluid collection. Breast implant-associated anaplastic large cell lymphoma is suspected. Analysis of the fluid will most likely show which of the following tumor markers?
A) Anaplastic lymphoma kinase
B) CD3
C) CD5
D) CD30
E) Human germinal center-associated lymphoma (HGAL)
The correct response is Option D.
Breast implant-associated anaplastic large cell lymphoma (BIA-ALCL) has been associated primarily with textured implants. Thought to be related to chronic inflammation from subclinical infection, the presentation is typically with a late-onset seroma. Workup of a late-onset seroma includes aspiration of the seroma and cytological/immunohistochemical analysis. The predictive value is most significant on the initial aspiration because of the presumed larger concentration of malignant cells; as the seroma reforms, there is a hypothesized dilutional aspect.
BIA-ALCL neoplastic cells are strongly CD30-positive, but CD30 is a necessary but insufficient criterion to make the diagnosis since it can be displayed in nonmalignant situations as well (such as in viral infection).
While anaplastic lymphoma kinase (ALK) is associated with systemic ALCL in 60% of cases, it has not been associated with BIA-ALCL. Thus, while ALK assessment is considered necessary to the analysis, it is expected to be negative. BIA-ALCL neoplastic cells variably lose expression of CD3 and CD5. Compared with other forms of ALCL, BIA-ALCL is associated with a more indolent course, although a subset of patients do have an aggressive course. Human germinal center-associated lymphoma (HGAL) is associated with B-cell lymphoma.
A 62-year-old woman undergoes left mastectomy with axillary lymph node dissection and tissue expander reconstruction. A drain is placed adjacent to the tissue expander and in the axilla. An intravenous catheter is placed in her left arm, and blood pressure is measured from same arm. BMI is 42 kg/m2. Which of the following risk factors is most significantly associated with lymphedema in this patient?
A) Compression from a blood pressure cuff
B) Drain placement in the axilla
C) Obesity
D) Placement of an intravenous catheter
E) Tissue expander reconstruction
The correct response is Option C.
Obesity (BMI >30 kg/m2) is the most significant risk factor for lymphedema from the listed choices. Patients who undergo axillary lymphadenectomy and radiation are at an approximately 30% risk for acquiring lymphedema. Obese individuals are at higher risk. In addition, obesity-induced lymphedema is a phenomenon in which patients who reach a BMI of 50 to 60 kg/m2 have a high risk for lymphedema, in particular bilateral lower extremity lymphedema, without any other inciting events.
Compression from a blood pressure cuff is unlikely to cause lymphedema. Lymphedema is primarily treated with compression (pneumatic, static). Evidence is lacking that an intravenous catheter increases the risk for lymphedema. Tissue expander reconstruction or any breast reconstruction does not increase the risk for lymphedema and neither does drainage tube placement.
A 76-year-old woman presents with swelling of her right reconstructed breast, which was performed with a textured implant 14 years ago. Ultrasound demonstrates an uncomplicated fluid collection. The patient denies pain, fevers, or chills. Enrichment of which of the following cell surface markers within the aspirated fluid is suggestive of breast implant-associated anaplastic large cell lymphoma?
A) CD3
B) CD15
C) CD30
D) CD34
E) CD45
The correct response is Option C.
Breast implant-associated anaplastic large cell lymphoma (BIA-ALCL), a type of T-cell lymphoma, is associated with textured implants. Initial diagnosis is often made following ultrasound. CD30 is a cell surface marker detected on T-cells associated with BIA-ALCL. The other cell surface markers are not associated with BIA-ALCL. These cells are also anaplastic lymphoma kinase (ALK) negative. CD3 and CD15 are nonspecific lymphocyte markers not related to BIA-ALCL. CD34 is an endothelial cell marker. CD45 is a marker expressed on all leukocytes.
A 49-year-old woman who underwent first-stage left breast reconstruction with a tissue expander presents for follow-up to discuss expander to implant exchange. The reconstructed side has more volume and superior fullness compared with the native breast, and the patient prefers the reconstructed side. A photograph is shown. In addition to implant exchange, which of the following would most likely give the patient the greatest satisfaction regarding the appearance of her breasts?
A) Left breast fat grafting
B) Left breast flap reconstruction
C) Right breast implant augmentation
D) Right breast mastopexy
E) No additional procedures
The correct response is Option C.
The patient shown in the initial photograph complains of lack of symmetry between the reconstructed breast and the native, contralateral side. The volume and superior fullness in the reconstructed breast are a result of an implant-based reconstruction. Studies have shown improved patient satisfaction with breast reconstruction when contralateral augmentation is performed for symmetry. For this patient who was happy with an implant-based reconstruction, symmetry was best achieved with a contralateral breast augmentation. In the additional image shown, she is pictured after tissue expander to implant exchange, nipple-areola complex reconstruction, and right breast augmentation. The other choices are less ideal and would not necessarily give the patient the symmetry or satisfaction she desires.
A 47-year-old woman comes to the emergency department because of wound separation. History includes immediate prepectoral breast reconstruction with placement of left tissue expander, and she is currently undergoing radiation therapy. Physical examination shows an approximately 0.5-cm area of incisional dehiscence with exposure of the device. Vital signs are stable, and inflammatory markers are mildly elevated. Which of the following is the most appropriate next step in management?
A) Admit the patient for intravenous antibiotic therapy and monitor the wound
B) Apply occlusive dressing and discharge the patient on oral antibiotic therapy
C ) Close the wound at bedside in the emergency department and discharge the patient on oral antibiotic therapy
D) Perform expander removal in the operating room
E) Perform operative replacement of the expander
The correct response is Option D.
Studies have shown that postmastectomy radiation therapy almost doubles the risk of complications, including wound breakdown. While attempts at implant salvage are tempting, they are often ultimately unsuccessful and may potentially delay necessary radiation treatments. Therefore, in the event of implant exposure during adjuvant therapy, the device should be removed and the mastectomy pocket closed over a surgical drain. This strategy will allow for the shortest delay in further oncologic treatments and does not preclude reconstruction at a later date. Closure of the wound over an exposed device should not be attempted, as any exposed device is assumed to be colonized, if not grossly infected. Although antibiotics may temporize the infectious process, it is unlikely that successful wound healing and retention of the prosthesis will occur after suppressive antimicrobials are stopped.
An otherwise healthy, 45-year-old woman presents for breast reconstruction. She underwent a mastectomy 1 year ago with no immediate reconstruction followed by post-mastectomy radiation therapy. She does not want anything performed to the contralateral breast and does not want to have an implant. She has a history of an abdominoplasty. The plastic surgeon plans to perform stacked profunda artery perforator flaps for the unilateral reconstruction. Which of the following is the most appropriate option for the recipient vessels?
A) Ipsilateral and contralateral antegrade internal mammary vessels
B) Ipsilateral antegrade and retrograde internal mammary vessels
C) Ipsilateral antegrade and retrograde thoracodorsal vessels
D) Ipsilateral antegrade internal mammary and thoracoacromial vessels
E) Ipsilateral antegrade thoracodorsal and thoracoacromial vessels
The correct response is Option B.
It has been demonstrated that the retrograde intermammary vessels are a viable and reliable choice for stacked flap reconstruction. The benefit of using these as the recipient vessels is that it does not add another recipient site to the operation.
Ipsilateral and contralateral antegrade internal mammary vessels are incorrect because the patient does not want to have any procedures performed on her contralateral breast, although this has been described as an option for autologous breast reconstruction.
The thoracodorsal vessels, prior to development of the internal mammary vessels as the preferred option for autologous breast reconstruction, were commonly used for recipients, but utilizing these can negate the option of a latissimus dorsi as a salvage procedure in the setting of flap failure, especially if the plastic surgeon were to use the antegrade and retrograde vessels. Ipsilateral antegrade internal mammary and thoracodorsal vessels would be correct as well, but it was not given as an option. Thoracoacromial vessels are not typically used in autologous breast reconstruction, aside from being a lifeboat for venous outflow.
Which of the following legislative acts mandates insurance coverage of breast reconstruction after total mastectomy as well as coverage of any associated symmetry procedures for the contralateral breast?
A) Affordable Care Act
B) Breast Cancer Patient Education Act
C) SB-255 Amendment to the Knox-Keene Health Care Service Plan Act
D) Women’s Health and Cancer Rights Act
The correct response is Option D.
The Women’s Health and Cancer Rights Act of 1998 (WHCRA) is a federal law that mandates the coverage of breast reconstruction after mastectomy as well as coverage of any associated symmetry procedures for the contralateral breast. Although this federal law was enacted more than 20 years ago, there are still significant disparities in access to breast reconstruction and a lack of education regarding the options available for breast reconstruction.
The Breast Cancer Patient Education Act of 2015 is a federal law that requires the Secretary of Health and Human Services to implement an educational campaign to inform breast cancer patients about access, availability, and options for breast reconstruction after mastectomy. SB-255 is an amendment in the state of California to the Knox-Keene Health Care Service Plan Act that includes “lumpectomy” for treatment of breast cancer in the definition of “mastectomy” and mandates access to insurance coverage of breast reconstruction after lumpectomy in the state of California. It is important to note that the WHCRA only mandates coverage of breast reconstruction after mastectomy, not after breast conservation therapies such as lumpectomy. In fact, there is no current legislation mandating insurance coverage for all types of breast reconstruction, including breast reduction, mastopexy, or implant complications after aesthetic surgeries.
The Affordable Care Act (ACA) is a comprehensive health care reform law enacted in March of 2010. The three primary goals of the ACA are to make affordable health insurance available to more people, to expand the Medicaid program to cover all adults with income below 138% of the federal poverty level, and to support innovative medical care delivery methods designed to lower the costs of health care generally. There is nothing specifically in reference to breast cancer or breast reconstruction care within the ACA.
A 56-year-old woman with breast cancer undergoes bilateral mastectomy and immediate breast reconstruction with deep inferior epigastric perforator (DIEP) flaps. She has an uneventful recovery and is discharged home on postoperative day 4. Which of the following best describes the expected postoperative changes to the lower extremity venous system during this patient’s hospital stay?
A) There is decrease in diameter of the common femoral vein
B) There is increase in flow velocity of the common femoral vein
C) There is no change to the venous circulation
D) There is persistent venous stasis through the day of discharge
E) There is venous stasis, influenced by unilateral versus bilateral flap reconstruction
The correct response is Option D.
There is an increased risk of deep venous thrombosis associated with autologous breast reconstruction. Studies have tried to correlate autologous breast reconstruction with decreased venous return and stasis.
When compared with baseline levels, the common femoral veins have increased diameter and decreased flow velocity. These changes persist through the day of discharge. Since lower abdominal tissue is harvested and tight abdominal closure is performed in both unilateral and bilateral autologous breast reconstruction, there is no difference in venous stasis postoperatively when comparing both groups.
A 43-year-old woman with a history of Stage I T1N0 invasive ductal carcinoma of the right breast presents 15 years after undergoing bilateral mastectomy, negative right sentinel lymph node biopsy, and staged expander to implant breast reconstruction. Over the past 3 months, her left reconstructed breast has become significantly larger than her right. On examination, there are no skin lesions, palpable masses, or axillary lymphadenopathy. Which of the following is the most appropriate next step in the workup of this patient?
A) Ultrasound
B) Mammography
C) PET-CT
D) MRI
The correct response is Option A.
The patient presents 15 years after bilateral mastectomy and staged expander to implant breast reconstruction with a new finding of left reconstructed breast enlargement. This may be due to a large late periprosthetic fluid collection, Baker Classification Grade III and IV capsular contracture can give the impression of breast enlargement because of the increased projection and vertical height of the breast contour. Any patient presenting with a late periprosthetic fluid collection should be evaluated for breast implant-associated anaplastic large cell lymphoma (BIA-ALCL). In this patient, it is unknown what type of implant she has; therefore, radiologic evaluation is warranted.
Physical examination and a breast ultrasound would distinguish between these two causes of perceived enlargement of a breast after implant-based breast reconstruction. Ultrasound can also identify capsular masses and provides an opportunity to aspirate the fluid collection, which often provides symptomatic relief for the patient, as well as an opportunity to perform cytology to analyze lymphocyte numbers and characteristics, in addition to flow cytometry to measure anaplastic lymphoma kinase negativity and CD30 cell surface receptor positivity.
Presentation with BIA-ALCL can take many years to develop, with a median 10 years to fluid collection development. Surgical treatment for BIA-ALCL can vary with the stage of presentation, but BIA-ALCL confined to the periprosthetic fluid can be effectively treated with capsulectomy and implant removal. The majority of cases of BIA-ALCL present with late-onset seroma (66-80%), whereas the second most common presentation is an isolated mass within the capsule around the implant.
PET-CT is often performed as part of a staging evaluation after the diagnosis of BIA-ALCL is confirmed. Mammography is a breast cancer screening tool, but has no role in post-mastectomy evaluation.
A prone breast MRI (or ultrasound) is recommended 5 to 6 years after silicone breast implant placement and every 2 years thereafter to evaluate the integrity of the implant shell, but has no role in the management of BIA-ALCL.
An otherwise healthy 41-year-old woman is scheduled to have bilateral prophylactic NSM for a BRCA1 mutation. Which of the following is an advantage of prepectoral implant reconstruction when compared with submuscular implant reconstruction?
A) There are significantly more acute postoperative surgical complications
B) There is a higher revision rate
C) There is a lower rate of animation deformity
D) There is a lower rate of upper pole rippling and implant palpability
E) There is more pain and functional impairment
The correct response is Option C.
The patient is a young, healthy, thin woman presenting for bilateral breast reconstruction following prophylactic mastectomies because of increased lifetime risk of breast cancer. She will maintain her entire breast skin envelope because she has planned nipple-sparing mastectomies and does not wish to increase her breast size with the operation. She has questions about the plane of implant placement above or below the pectoralis muscle and the answer choices provide the opportunity to counsel her on direct to implant versus staged expander to implant breast reconstruction.
Because of the lack of camouflage afforded by placement of the pectoralis muscle over the upper pole of the breast implant, prepectoral breast reconstruction is associated with increased rippling of the upper portion of the breast. This patient is thin according to BMI and so will have an increased risk of upper pole rippling that can be improved with subsequent fat grafting, provided she has adequate donor sites for fat harvest.
Several patient series reporting on early outcomes after prepectoral breast reconstruction have used a partially submuscular patient cohort as a comparison for acute postoperative complications. The overwhelming majority of these series showed no significant differences in acute postoperative outcomes and revision rates between techniques.
Postoperative functional assessments have demonstrated less pain and earlier return of function after prepectoral implant placement compared to submuscular implant placement. Re-siting of submuscular implants to a prepectoral plane have demonstrated resolution of animation deformity.
Algorithms for patient selection have slowly evolved over the past five years with the only constant recommendation being that the ideal candidate has a BMI less than 30 kg/m2. Earlier series emphasized mastectomy skin flap thickness, whereas more recent studies focus on skin flap viability. Earlier studies considered radiation treatment a contraindication, whereas more recent reports demonstrate the negative impact of radiation on pectoralis major fibrosis in submuscular reconstruction as compared with prepectoral implant placement.
Lactiferous ducts in the human embryo are derived from which of the following types of cell populations?
A) Endodermal
B) Epithelial
C) Mesenchymal
D) Neural crest
E) Pluripotential
The correct response is Option B.
As early as 6 weeks of gestation, discrete areas of epithelial proliferation occur on the ventral thorax. These areas evolve into buds that then canalize and form secondary buds that give rise to lactiferous ducts. These, along with secretory acini that originate in puberty, constitute the parenchyma of the breasts. These ducts are surrounded by mesodermal-derived mesenchymal cells, which in turn develop into the breast stroma composed of smooth muscle cells, capillary endothelial cells, and adipocytes. Neural crest cells give rise to pigmented cells and other structures but are not involved with embryogenesis of the breasts. Endodermal cell lines produce the lining of the gut and contribute to development of the liver and pancreas but not the breasts. Pluripotential cells do not comprise the parenchyma nor the stroma of the developing breast.
Which of the following hormones in the mammary gland is critical for breast development during puberty?
A) Cortisol
B) Insulin-like growth factor-1 (IGF-1)
C) Platelet-derived growth factor (PDGF)
D) Prolactin
E) Vascular endothelial growth factor-C (VEGF-C)
The correct response is Option B.
While pubertal breast development depends on an estrogen surge, it is important to remember that breast development occurs downstream. The surge triggers pituitary growth hormone to stimulate mammary gland production of insulin-like growth factor-1 (IGF-1). IGF-1, in turn, causes proliferation and anti-apoptosis through a signaling cascade. Disruption of any factor along this pathway will result in abnormal breast development. Laron syndrome, for example, is an autosomal recessive disorder in which growth hormone insensitivity can cause delayed puberty as well as short stature. While high levels of prolactin can cause breast growth (and are thought to be responsible for ultimate breast development in Laron syndrome), prolactin is not in the mammary glands themselves.
In addition to the critical role IGF-1 plays during breast development, it also plays an important role in breast development during pregnancy. High levels of IGF-1 are also associated with increased breast volume and early-onset breast cancer. High serum levels of IGF-1 are associated with both bad prognosis and increased mortality in breast cancer. Cortisol is a stress hormone not related to breast development. Platelet-derived growth factor has a primary role in blood vessel development, as does vascular endothelial growth factor (VEGF). VEGF-C has a function in lymphangiogenesis.
A 55-year-old woman has ductal carcinoma in situ located approximately 6 cm from the nipple on the lateral upper quadrant of the left breast. Which of the following is the minimum margin of excision if she decides to proceed with lumpectomy followed by radiation therapy?
A) 1 mm
B) 2 mm
C) 5 mm
D) 1 cm
E) 2 cm
The correct response is Option B.
Consensus guidelines recommend a 2-mm minimum margin for patients undergoing breast-conserving therapy. Margins over 2 mm are not associated with further risk of local recurrence.
Primary treatment options for women with ductal carcinoma in situ (DCIS) are lumpectomy plus whole breast radiation with or without boost, total mastectomy - with or without SLNB with optional reconstruction, or lumpectomy alone. For patients with DCIS treated with breast conserving therapy, which includes lumpectomy followed by radiation, margins of at least 2 mm are associated with a reduced risk of ipsilateral breast tumor recurrence relative to narrower negative margin widths. However, a negative margin width wider than 2 mm is not supported by the evidence. An analysis of specimen margins and specimen radiographs should be performed to ensure that all mammographically detectable DCIS has been excised. In addition, a postexcision mammogram should be considered where appropriate.
A 54-year-old woman presents for follow-up examination after undergoing left mastopexy for improved symmetry 6 months ago. Medical history includes breast cancer. The patient reports some discomfort overlying a firm 1.5-cm mass that is palpable in the subcutaneous plane of the left breast. Which of the following is the most appropriate next step in management?
A) Fine-needle aspiration
B) Surgical excision
C) Ultrasound imaging
D) Warm compresses
E) Observation only
The correct response is Option C.
The most appropriate next step in management is to obtain imaging. Ultrasound can identify and characterize lesions such as fat necrosis, which is the most likely cause of this patient’s palpable mass in the postoperative period. Such imaging can confirm the physical examination findings and guide the best course of treatment (ie, aspiration versus excision). Observation or warm compresses are inadequate in addressing these findings or in obtaining a diagnosis. Once the benign nature and characteristics of the lesion are better understood, then treatment with bedside aspiration or formal excision of the mass can be undertaken.
According to the 2017 US breast cancer mortality data, three states with appropriately powered data achieved statistically equivalent mortality rates between non-Hispanic African American and non-Hispanic Caucasian women. Which of the following factors was most likely implicated in the improvement in mortality rates in the non-Hispanic African American women in these states?
A) Non-Hispanic African American women are more affluent
B) Non-Hispanic African American women are younger
C) Non-Hispanic African American women have fewer “triple-negative” aggressive breast cancers
D) Non-Hispanic African American women have more access to screening mammography and in situ diagnosis
The correct response is Option D.
Social determinants of health include where a person resides, what exposures are present, what diet is eaten, how much stress is present, and other lifetime experiences. Social determinants of health affect who gets disease and how well they can be cared for when they have disease.
According to the 2020 cancer statistics, death from female breast cancer has declined overall by 40% in the United States since 1989.
The 2017 breast cancer statistics look at breast cancer in a state-by-state fashion demonstrating that those gains in survival have not been uniformly spread among the populations, with non-Hispanic African American women suffering higher death rates by age group, staging, and oncotyping groups.
While there are no data to discuss why non-Hispanic African American women tend to develop cancer younger or develop more “triple negative” breast cancers, there has been evidence presented in the 2017 breast cancer statistics that better access to care may improve the stage at diagnosis. In seven states, the mortality rates were statistically the same. In three of those states—Massachusetts (an early state to establish mandatory health insurance), Connecticut, and Delaware—there were sufficient cohort numbers of non-Hispanic African American women with an in situ diagnosis, which is used as a proxy for access to screening mammography. In the four other states, there was statistical equivalence, but they were underpowered. The implication of these data is that better access to mammography/care lowers mortality for non-Hispanic African American women with breast cancer. These studies did not address affluence, but they did rule out age as a factor.
A 56-year-old woman is evaluated 6 hours after undergoing bilateral breast reconstruction with a deep inferior epigastric perforator (DIEP) flap. Doppler examination shows strong arterial signals in both flaps. The right breast appears bluish with a capillary refill time of 1 second compared to 3 seconds on the left side. Which of the following is the most appropriate next step?
A) Administration of tissue plasminogen activator
B) Application of leeches
C) Application of nitroglycerin ointment
D) Exploration in the operating room
E) Observation
The correct response is Option D.
The patient described has evidence of venous congestion. The reported incidence of venous congestion in free tissue breast reconstruction ranges from 2 to 20%. Causes include venous thrombosis, inadequate perforator selection, and superficial venous system dominance with lack of sufficient communication to the deep system. Signs of venous compromise include the following: cyanotic/blue color, brisker than normal capillary refill, increased tissue turgor, cooler temperature compared to normal skin (greater than 2 degrees), rapid bleeding of dark blood with pinprick, and absence of continuous venous Doppler signal. The most appropriate course of action in this scenario is emergent exploration in the operating room to assess the vascular pedicle for thrombosis, compression from hematoma, kinking, or superficial system dominance. Flap salvage rate is directly tied to timing of exploration, with higher salvage rates in flaps explored within 6 hours of identification of compromise.
Early recognition and rapid exploration of compromised flaps are the most important factors predicting flap salvage, so observation would be unacceptable. Tissue plasminogen activator is useful if diffuse clotting is suspected within the flap, but should only be given locally within the flap. Leeches can be a useful adjunct postoperatively after employing the other maneuvers described above, but would not resolve the underlying problem in this case. Application of topical nitroglycerin can improve venous congestion in random skin flaps, but has no role in the management of acute microvascular thrombosis.
An otherwise healthy 54-year-old perimenopausal woman is scheduled for a mastectomy for biopsy-proven right-sided grade 2 ductal carcinoma. According to the National Comprehensive Cancer Network (NCCN) guidelines, postmastectomy radiation therapy will be the standard of care for this patient if she has which of the following surgical outcomes?
A) 1-cm surgical margins, four positive axillary lymph nodes
B) 1-cm surgical margins, one positive axillary sentinel node
C) 1-mm surgical margins, no positive axillary nodes
D) 5-mm surgical margins, no positive axillary nodes
E) 5-mm surgical margins, three positive axillary nodes
The correct response is Option A.
Traditionally, the need for radiation therapy has been a contraindication for implant-based reconstruction, and autologous reconstruction is the conservative gold standard for women with advanced cancer needing postmastectomy radiation. More recently, there have been reports of successful implant based reconstruction in the setting of postmastectomy radiation that have similar complication profiles and good oncologic outcomes compared with autologous reconstruction. Protocols vary between those that radiate the expander and then expand, and those that expand and then radiate the permanent implant. Being able to anticipate which patient will require postmastectomy radiation is essential for joint decision making about breast reconstruction with the patient prior to her mastectomy.
By National Comprehensive Cancer Network (NCCN) guidelines, relative indications for postmastectomy radiation therapy include: positive sentinel node with unknown status of other axillary nodes, one to three positive nodes on permanent histology, and close surgical margins (less than 5 mm). Postmastectomy radiation is recommended as the standard of care in the situations of positive surgical margins with the inability to get clear margins and four or more positive lymph nodes.
A healthy 45-year-old woman with a history of breast malignancy underwent bilateral mastectomy and reconstruction with tissue expanders followed by exchange for cohesive silicone gel implants eight years ago with routine postoperative MRI surveillance. She comes to the office to report pain and tightness in the right breast that has gradually increased over the past month. On examination, temperature is 36.8°C (98.2°F), blood pressure is 112/76 mmHg, and heart rate is 68 bpm. The right breast appears fuller than the left breast; otherwise, the right implant is in a symmetric position with the left side. The skin is otherwise normal in appearance, and there is no tenderness on palpation. Which of the following is the most appropriate next step in management?
A) MRI of the right breast to assess the integrity of the implant
B) One week of an oral antibiotic and prednisone taper
C) Operative exploration, culture, and replacement of implant
D) Referral of the patient back to her medical and surgical oncologists
E) Ultrasound of the right breast and fine-needle aspiration of any fluid
The correct response is Option E.
Patients that 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 seroma that have presented as early as 4 months.
The first step in evaluation for BI-ALCL is an ultrasound followed by fine needle aspiration is 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. CD30 antibody labels anaplastic large cell lymphoma cells. CD30 is a transmembrane cytokine receptor belonging to the tumor necrosis factor receptor family and characteristically stains ALCL cells.
MRI for implant integrity and referral to her Oncologist may be needed but it is not the most appropriate next step. BIA-ALCL needs to be ruled out. Immediate operative exploration is not indicated before fluid aspiration and immunohistochemistry evaluation. Antibiotics and prednisone is not indicated in this patient without evidence of infection or inflammation (red breast syndrome).
In women undergoing prosthetic breast reconstruction complicated by an expander/implant infection, which of the following is the most common gram-negative bacteria isolated from cultures?
A) Escherichia coli
B) Klebsiella
C) Proteus
D) Pseudomonas
E) Serratia
The correct response is Option D.
Tissue expander/implant-based breast reconstruction remains the most common form of reconstruction after mastectomy. One of the most potentially devastating complications of this form of breast reconstruction is an implant infection with need for removal of the expander/implant. The mean reported incidence of implant infection after breast reconstruction is 8%, with a range of 1 to 35%. When cultures are obtained, the most common causative bacteria on microbiology examination are gram-positive organisms (41 to 83%), specifically, Staphylococcus species (56 to 76.5%). Gram-negative bacteria accounted for 15.3 to 28.6%, with Pseudomonas (10.7 to 14%) being the most common gram-negative bacteria present on microbiology examination.
A patient with a history of breast cancer undergoes nipple-sparing mastectomy of the right breast with immediate implant-based reconstruction. Ten months after surgery, the patient starts to recover sensitivity at the nipple. Which of the following nerves is most likely providing sensitivity to the nipple-areola complex in this patient?
A) Anterior branch of the fourth intercostal nerve
B) Anterior branch of the second intercostal nerve
C) Lateral branch of the fifth intercostal nerve
D) Lateral branch of the fourth intercostal nerve
E) Lateral branch of the second intercostal nerve
F) Lateral branch of the third intercostal nerve
The correct response is Option A.
The nipple and areola of the breast are innervated by both the anterior and lateral cutaneous branches of the third, fourth, or fifth intercostal nerves. The anterior and lateral cutaneous branches of the second and sixth intercostal nerves innervate breast skin only.
In anatomical studies conducted in female cadavers, the fourth intercostal nerve’s lateral cutaneous branch supplied the nipples in 93% dissected breasts. The third and fifth intercostal lateral branches were found to innervate the nipple alone in 3.6%. However, the fourth intercostal lateral branch penetrates the deep fascia in the midaxillary line, takes an inferomedial course to reach the midclavicular line, and continues through the glandular tissue towards the posterior surface of the nipple. Thus, when a mastectomy is performed, this lateral branch is the most likely one to be dissected.
On the other hand, the anterior cutaneous branches take a superficial course, as they run in the subcutaneous tissue close to the skin and reach the nipple from the lateral side. According to this, the anterior branch of the fourth intercostal nerve is most likely providing sensitivity to the nipple-areolar complex after nipple-sparing mastectomy.
A 53-year-old woman is evaluated for left-sided nipple reconstruction after mastectomy. She has scars on the left breast from a previous breast biopsy, as well as from the mastectomy itself. Nipple reconstruction must be designed around the scars. In single-pedicle nipple reconstruction, which of the following provides the blood supply to the pedicle?
A) Internal mammary artery perforators
B) Posterior intercostal arteries
C) Subdermal plexus
D) Superior intercostal artery
E) Thoracoacromial artery perforators
The correct response is Option C.
Single-pedicle nipple reconstructions, which include such techniques as the skate flap, star flap, C-V flap, and opposing tab flaps as well as other variations, create nipples from remaining mastectomy skin through adjacent tissue transfer. The flap derives its blood supply from the subdermal plexus.
The creation of the flap must keep this blood supply in mind. The flap design must avoid previous scars at the flap base and must integrate the subcutaneous fat at the base of the pedicle.
The internal mammary artery supplies the breast itself and the nipple-areola complex, and the thoracoacromial artery supplies the pectoralis muscle and the breast. The posterior intercostal arteries supply the intercostal spaces. The superior intercostal artery arises from the costocervical trunk, off of the subclavian artery, and supplies the intercostal spaces.
A 41-year-old woman presents with right breast lobular carcinoma in situ (LCIS) involving a 1-cm area with no palpable axillary nodes. According to the TNM staging system, which of the following is this patient’s T classification?
A) Tx
B) Tis
C) T0
D) T1a
E) None; there is no TNM staging for LCIS
The correct response is Option E.
Lobular carcinoma in situ (LCIS) has been removed from the staging classification system in the 8th edition and is no longer included in the pathologic tumor in situ (pTis) category. LCIS is treated as a benign entity with an associated risk for developing carcinoma in the future but not as a malignancy capable of metastases. There is a small subset of LCIS that has high-grade nuclear features and may exhibit central necrosis. This subset has been referred to as pleomorphic LCIS and has histologic features that partially overlap the features of ductal carcinoma in situ (DCIS), including the potential to develop calcifications detectable by mammography. The expert panel debated whether to include this variant of LCIS in the pTis category; however, there are insufficient data in the literature regarding outcomes and reproducible diagnostic criteria for this LCIS variant. Cases exhibiting DCIS and LCIS are classified as pTis (DCIS).
A 44-year-old woman presents in evaluation for breast reconstruction with biopsy-proven left breast-infiltrating ductal carcinoma after routine mammography discovered a 7-cm lesion. She has been referred to medical oncology and genetic testing is pending. Her past medical history is significant for hypertension and scleroderma. On examination, she has grade I ptosis and wears a size 34A brassiere. During the consultation, the patient reports a strong preference for lumpectomy and oncoplastic reconstruction over total mastectomy. Which of the following is most likely to increase this patient’s chances of qualifying for breast-conserving therapy?
A) Active scleroderma
B) BRCA-1 gene mutation
C) Multicentric tumor
D) Preoperative chemotherapy
E) Small-sized breasts
The correct response is Option D.
Preoperative chemotherapy could increase this patient’s chances of qualifying for locoregional treatment (partial mastectomy or lumpectomy). Studies have shown that breast conservation rates are improved with preoperative systemic therapy, which can also render inoperable tumors resectable. Other potential benefits of preoperative (neoadjuvant) chemotherapy include providing important prognostic information based on response to therapy, minimizing the extent of axillary surgery, and allowing time for genetic testing and reconstructive planning prior to surgery. A small-sized breast would likely provide insufficient uninvolved breast tissue for breast-conserving therapy after resection of a large (7 cm) mass. The same applies to multicentric tumors.
Whole breast irradiation is strongly recommended after lumpectomy, with studies showing a favorable effect in reducing the 10-year risk of recurrence (19% versus 35%) and the 15-year risk of breast cancer death (21% versus 25%). Therefore, patients with (relative) contraindications to radiation therapy, such as lupus or scleroderma (connective tissue disease involving the skin), should ordinarily be offered total mastectomy, particularly if this resolves the need for radiation therapy. While radiation therapy would likely still be considered for this particular patient even after total mastectomy (tumor size greater than 5 cm), the diagnosis of scleroderma itself does not increase her chances of qualifying for breast conservation surgery. BRCA-1 gene mutation and other genetic predispositions to breast cancer are relative contraindications for breast-conserving therapy. These patients may be considered for prophylactic bilateral mastectomy for risk reduction.
A 54-year-old woman is evaluated for nipple-areola complex reconstruction after mastectomy and silicone implant-based reconstruction. During discussion of the risks and benefits of a C-V flap, the patient asks about the long-term results of different techniques. Which of the following is the most likely long-term complication of a single-pedicle nipple-areola reconstruction?
A) Atrophic scarring
B) Delayed nipple necrosis
C) Hypertrophic scarring
D) Implant exposure
E) Loss of projection
The correct response is Option E.
Single-pedicle nipple reconstructions, which include techniques such as the skate flap, star flap, C-V flap, and opposing tab flaps as well as other variations, create nipples from remaining mastectomy skin through adjacent tissue transfer. The flaps derive their random-pattern blood supply from the subdermal plexus.
The creation of the flap must keep this blood supply in mind. The surgical technique must avoid previous scars at the base of the flap design and must integrate the subcutaneous fat at the base of the pedicle.
While hypertrophic and atrophic scarring can occur, they are not the most common long-term effects, and are more a function of patient characteristics than flap characteristics.
Implant exposure can occur with scar breakdown, but this is an early rather than a late complication.
Delayed nipple necrosis is technically not correct because the nipple is no longer present, and is not correct of the nipple reconstruction because necrosis of the flaps, if it occurs, usually occurs early.
A 45-year-old woman presents with right breast cancer and is planning a nipple-sparing mastectomy and tissue expander placement. She is specifically interested in a carbon dioxide–based expander. Which of the following is a disadvantage of this device compared with a saline tissue expander?
A) Extrusion
B) Inability to deflate
C) Increase in wound dehiscence
D) Increase in wound infection
E) Possible device dislocation
The correct response is Option B.
The carbon dioxide-based tissue expander (AeroForm) is a fixed-volume device and has an inability to deflate the expander.
In a prospective, multicenter, randomized controlled trial comparing carbon dioxide–based expanders and saline tissue expanders, there were no statistically significant differences in rates of wound infection, extrusion, device dislocation, or wound dehiscence. Advantages of the carbon dioxide–based expander include a more rapid expansion process and a shorter time to implant exchange. The device is self-contained and patient-controlled, so there are no needles required and possibly fewer physician office visits.
A 55-year-old woman with a BRCA gene mutation elects to undergo bilateral mastectomy with reconstruction using a deep inferior epigastric perforator flap. BMI is 41 kg/m2. Physical examination shows both supra- and infraumbilical adiposity with excess skin and a mature cesarean delivery scar. This patient has the highest risk for which of the following early postoperative complications?
A) Abdominal wall bulge
B) Abdominal wall hernia
C) Delayed wound healing of donor site
D) Fat necrosis of the flap
E) Flap failure
The correct response is Option C.
The highest risk is for delayed wound healing of the donor site. Because of the patient’s morbid obesity and prior cesarean delivery scar, she has the highest risk for some form of wound breakdown or prolonged wound healing. This risk can be as high as 50 to 60% for morbidly obese patients. These trends are similar in patients following reconstruction with a transverse rectus abdominis musculocutaneous (TRAM) flap.
To reduce these risks, minimal undermining is recommended and only done if necessary. Techniques to preserve all cutaneous perforators will help reduce the risk associated with closure of the donor sites.
While morbid obesity can be associated with increased abdominal wall thickness, there is no correlation with the occurrence of abdominal wall bulge or hernia. The risks for these complications are less than 2%.
Patients with morbid obesity can have shorter operative times, but there is no correlation with overall flap failure, with rates reported to be less than 1%. This is also seen in pedicled and free TRAM flap reconstructions.
Rates of fat necrosis of the flap can be as high as 10 to 15% in patients undergoing reconstruction, but this risk is not affected by body habitus or body mass index and is lower than the risk for delayed wound healing.
A 44-year-old previously healthy woman comes to the clinic because of a 2-week history of a painless mass in the left breast. She initially felt this mass while taking a shower. Her mother was diagnosed with fibrocystic changes. The patient denies alcohol consumption and smoking cigarettes. Examination of the left breast shows a 5-cm mobile, painless mass in the left upper external quadrant without nipple discharge, skin retractions, or color changes. Examination of a specimen obtained on biopsy discloses a phyllodes tumor, and surgical excision of the lesion is planned. Which of the following is the most important factor to prevent local recurrence after surgery?
A) Adjuvant radiotherapy
B) Concurrent axillary node dissection
C) Postoperative chemotherapy
D) Surgical margins less than or equal to 0.5 cm
E) Wide surgical margins
The correct response is Option E.
In a young woman who has no history of breast cancer, presents with a painless mass, and has a mammogram suggestive of fibroadenoma but a core needle biopsy showing stromal hypercellularity with atypical spindle cells and a high mitotic rate, a phyllodes tumor must be suspected.
Phyllodes tumors are uncommon fibroepithelial breast tumors that behave like benign fibroadenomas, although they have a high propensity to recur locally. More aggressive tumors can metastasize distantly. Surgery is the preferred treatment for this condition. In this context, surgical margins greater than or equal to 1 cm have been associated with a lower recurrence rate in borderline and malignant tumors.
Axillary lymph node involvement is rare. Wide local excision or mastectomy with appropriate margins is the preferred clinical intervention.
Based on limited data, the role of systemic chemotherapy in phyllodes tumors is limited. Patients with benign or borderline phyllodes tumors are usually cured with surgery and should not be offered chemotherapy unless they develop unresectable metastases.
Local recurrence rate is higher after excision with narrower margins than broader ones. The efficacy of postoperative adjuvant radiotherapy for a breast phyllodes tumor is not clear. In clinical practice, the utilization of adjuvant radiotherapy for a phyllodes tumor appears to be modest.
A 35-year-old woman presents with unilateral swelling that has developed over the past 3 months. She underwent bilateral nipple-sparing mastectomy with immediate implant reconstruction with textured, round silicone gel implants 8 years ago. Ultrasound confirms periprosthetic seroma without any masses. Which of the following is the most appropriate next step in the management of this patient?
A) Core needle biopsy
B) Fine-needle aspiration
C) Implant removal and capsulectomy
D) MRI
E) Positron emission tomography (PET) scan
The correct response is Option B.
The clinical scenario is concerning for breast implant–associated anaplastic large-cell lymphoma (BIA-ALCL). Aspiration of the fluid seen on ultrasonound and pathologic evaluation is necessary to confirm the diagnosis. Following the National Comprehensive Cancer Network guidelines, initial workup of an enlarged breast should include ultrasound evaluation specifically for a fluid collection, a breast mass, or enlarged regional lymph nodes (axillary, supraclavicular, and internal mammary).
MRI is appropriate for cases where ultrasound is indeterminate or requires further confirmation. This patient does not have an identifiable mass amenable to core biopsy. Positron emission tomography (PET) scan is beneficial in confirmed cases to identify associated masses, chest wall involvement, regional lymphadenopathy, and/or metastasis. Implant removal and capsulectomy is appropriate once the diagnosis is confirmed.
A 50-year-old woman presents to the clinic to discuss breast reconstruction after bilateral mastectomy. She is interested in free tissue transfer. She has a diagnosis of systemic lupus erythematosus treated with chronic steroid therapy and wants to know if she is an appropriate candidate for free flap reconstruction. Which of the following statements best describes the surgical risks for this patient with lupus compared with the general population?
A) Higher rate of free flap failure
B) Higher risk of a thromboembolic event
C) Similar rate of hernias after abdominally based free flaps
D) Similar rates of infection
The correct response is Option B.
The statement which best describes the surgical risks for a patient with lupus undergoing free tissue transfer for breast reconstruction is that the patient has a higher risk of a thromboembolic event than the average patient.
The rate of free flap failure in patients with lupus is similar to patients without lupus. Chronic steroid use increases the risk of wound healing complications in patients with lupus, rather than increases the risk of free flap failure. Additionally, patients with lupus have an increased risk of abdominal wall bulge and hernia after abdominally based free flaps compared with the average population. Chronic steroid use also suppresses the immune system, predisposing patients treated with steroids to increased rates of infection compared to patients not taking steroids.
A 19-year-old woman with a medical history significant for Poland syndrome and a BMI of 19 kg/m2 undergoes first-stage breast reconstruction with a tissue expander that is complicated by extrusion and infection 40 days after implantation. A photograph is shown. Attempts at implant salvage are made. The presence of which of the following factors is most likely to lead to decreased salvage rates?
A) BMI of 19 kg/m2
B) Culture-positive Staphylococcus sp
C) Hemoglobin A1c of 6.5%
D) Prepectoral placement of the device
E) Use of acellular dermal matrix
The correct response is Option B.
It has been shown that successful breast device salvage in breast reconstruction is possible if caught early. However, there are associated factors with failure, including culture-positive Staphylococcus (epidermidis or aureus), as demonstrated by several studies. Other associated risk factors for failure include obesity, poorly-controlled diabetes, smoking, history of radiation therapy, postoperative seroma, and early contamination of the implant with biofilm formation. Therefore, prompt and aggressive intervention is warranted in these situations where the device is threatened by either infection and/or exposure. This includes both surgical and antimicrobial options.
In a 2017 study, prepectoral and subpectoral placement demonstrated comparable complications. Acellular dermal matrix did not increase failure rates.
A 42-year-old woman with a history of a cesarean delivery from a low-transverse abdominal incision is scheduled to undergo a unilateral deep inferior epigastric perforator (DIEP) flap breast reconstruction. BMI is 28 kg/m² and the distance from nipple to sternal notch is 24 cm per side. This patient’s history of cesarean delivery is most likely to have which of the following effects?
A) Decreased abdominal seroma
B) Decreased flap venous congestion
C) Increased flap arterial thrombosis
D) Increased flap fat necrosis
E) No overall effect
The correct response is Option B.
Pfannenstiel incisions are the preferred access for cesarean deliveries. They are not a contraindication for abdominal-based flaps for breast reconstruction because the deep inferior epigastric circulation is not disturbed. However, the superficial epigastric circulation may be divided. The net result appears to be a more robust venous circulation with a protective effect against fat necrosis in the flap. This venous division causes a delay-type phenomenon—during healing increased branches are formed from the superficial epigastric circulation, and there is some evidence of new connections to the venae comitantes of the deep epigastric venous circulation.
There is evidence, however, for an increased rate of abdominal healing problems, including seroma (15% versus 6%), wound healing problems, and fat necrosis in the abdomen. There is no evidence for an effect on the arterial circulation of the flap.
A 50-year-old woman comes to the office 6 weeks after undergoing right mastectomy and immediate placement of a tissue expander. She reports swelling and redness of the right breast. A photograph is shown. Which of the following factors is most predictive of implant salvage failure in this patient?
A) Culture positive for Pseudomonas species
B) Elevated body mass index
C) Periprosthetic seroma
D) Presence of cellulitis
E) Previous irradiation
The correct response is Option A.
Immediate implant-based reconstruction has become increasingly popular over the past two decades, accounting for over 70% of all reconstructions in the United States. The benefits of immediate reconstruction are numerous, including decreased recovery/number of required procedures and increased patient psychological well-being and aesthetic outcome. However, the complication (seroma, mastectomy flap necrosis, loss of implant, and infection) rates after implant-based reconstruction remain relatively high. Infection rates in the reported literature range from 2.5 to 24%.
Historically, periprosthetic infection or implant exposure mandated immediate implant removal. However, numerous studies over the past several decades have demonstrated implant salvage rates of 37.3 to 73% depending on the methods employed. Several studies have looked at the predictive factors that increase the risk of a failed salvage attempt. Salvage was typically defined as administration of systemic antibiotics (oral or intravenous), removal of the infected implant, partial/total capsulectomy, pocket curettage, implant pocket irrigation with antibiotic solution, and placement of a new device.
Factors associated with implant salvage failure include an elevated white blood cell count, elevated temperature, deep-seated pocket infection (purulent periprosthetic fluid), and atypical pathogens such as methicillin-resistant Staphylococcus aureus (MRSA) and Pseudomonas species. Spear et al. showed that 93.9% of mild implant infections (localized cellulitis) could be salvaged compared with a 30% salvage rate in the severe infection group. Factors such as smoking, chemotherapy, previous irradiation, mastectomy skin necrosis, increased BMI, and use of acellular dermal matrix (ADM) have demonstrated increased rates of implant-related infections, but these factors have not been demonstrated to increase the risk of implant salvage failure.
A 68-year-old woman comes to the office for a delayed breast reconstruction. She had right breast cancer and a mastectomy followed by chemotherapy and radiation therapy 1 year ago. BMI is 35 kg/m2. Medical history includes well-controlled type 2 diabetes mellitus, a previous cesarean section through a low transverse incision, and an open cholecystectomy through a subcostal incision. The patient requests autologous reconstruction, but the surgeon is not comfortable performing a free flap. Which of the following is the most appropriate method for reconstruction?
A) Bipedicled transverse rectus abdominis musculocutaneous (TRAM) flap
B) Contralateral pedicled TRAM flap
C) Ipsilateral pedicled TRAM flap
D) Surgical delay procedure followed by contralateral pedicled TRAM flap
E) Surgical delay procedure followed by ipsilateral pedicled TRAM flap
The correct response is Option D.
In this obese patient with right breast cancer and a previous subcostal incision, a delay procedure with a contralateral transverse rectus abdominis musculocutaneous (TRAM) flap is the most appropriate method for reconstruction. Although a contralateral TRAM flap can be performed without a delay procedure, it has been shown that the addition of a delay procedure decreases risks of ischemia to the flap. In addition, a delay procedure may also reduce risks of abdominal wall complications. In this patient, the subcostal incision excludes right-sided pedicled flap reconstruction, so an ipsilateral pedicled TRAM would not be the right choice, nor would a bipedicled TRAM flap.
Although there is controversy on which patients should have a delay procedure, the use of this technique has usually been limited to high-risk patients and to those requiring large amounts of tissue. Multiple reports have shown that obese patients undergoing a delay can decrease the risks of tissue related ischemia. In a paper by Wang et al., the delay procedure was performed at least 14 days prior to the reconstruction; however, other studies have shown improvements at 7 days. The procedure described consists of ligation of both deep inferior epigastric arteries and veins bilaterally accessed from an inferior flap incision. This can also be done laparoscopically. Some authors advocate more extensive incisions and elevating portions of the flap; however, there is little data to show that this is effective or necessary.
A 52-year-old woman undergoes autologous breast reconstruction with unilateral deep inferior epigastric perforator (DIEP) flaps. According to the Hartrampf model of perfusion zones, if the lateral row perforator vessels are used, in which chronological order will the flap zones be perfused?
A) I – II – III – IV
B) I – III – II – IV
C) II – I – III – IV
D) II – I – IV – III
E) IV – III – II – I
The correct response is Option B.
In medial perforator-based flaps, the zones are perfused in the order I – II – III – IV (A) as shown in the image. In lateral perforator-based flaps, however, the zones are perfused in the order I – III – II – IV (B).
A 64-year-old woman who is postmenopausal asks why she has not been prescribed hormone replacement therapy with estrogen and progestin like her mother was. Supplementation with these hormones is associated with an increased risk for which of the following?
A) Coronary artery disease
B) Diabetes
C) Endometrial cancer
D) Invasive breast cancer
E) Osteoporosis
The correct response is Option D.
Hormone replacement therapy has fallen out of favor because of a risk profile that is believed to exceed the potential benefits. Combined estrogen and progestin supplementation is thought to be associated with an increased risk for invasive breast cancer but may decrease the risk for diabetes and osteoporosis. It is thought to not impact the risk for coronary artery disease or endometrial cancer.
A 46-year-old woman who is 5 ft 7 in (170 cm) tall and weighs 135 lbs (61 kg) is evaluated one year following bilateral nipple-sparing mastectomy and immediate reconstruction with placement of 350-mL smooth, round silicone gel implants beneath the pectoralis major muscle. Since the surgery, she has experienced hyperdynamic deformity of her breasts. On physical examination, the breast reconstruction appears natural, and there is significant movement of the breasts when the patient flexes her chest. Which of the following is the most appropriate management for this patient?
A) Inject botulinum toxin into the pectoralis major muscle
B) Inject triamcinolone-40 into the areas of tenderness using ultrasound guidance
C) Move the implants to the prepectoral plane and cover them fully with acellular dermal matrix
D) Perform a breast MRI to assess for rupture of the implants
E) Refer the patient to a physical therapist for range of motion, massage, and ultrasound treatments
The correct response is Option C.
This patient is experiencing significant movement because her implants were placed beneath the pectoralis major muscles. While reconstruction options are limited in this otherwise healthy and very thin patient who is not a good candidate for fat grafting or pedicled or free tissue transfer, placing implants over the pectoralis major muscles and covering the implants fully with acellular dermal matrix would be the most appropriate method of reconstructing her breasts and addressing her concerns.
Physical therapy and muscle relaxants are unlikely to produce long-term improvement. An MRI would likely be nondiagnostic, and even if her implants were ruptured, change to a prepectoral plane is still indicated. Botulinum toxin type A is likely not as effective for long-term significant improvement as reoperation. Triamcinolone would not be effective for hyperdynamic deformity.
The capsules from patients with breast implant–associated anaplastic large-cell lymphoma (ALCL) have significant presence of which of the following bacteria?
A) Escherichia coli
B) Ralstonia pickettii
C) Staphylococcus aureus
D) Pseudomonas aeruginosa
E) Serratia marcescens
The correct response is Option B.
Most concerning in the past two decades is the incidence of breast implant–associated anaplastic large-cell lymphoma (ALCL). This entity was first diagnosed and associated with breast implants in 1997, and is almost only associated with a history of textured implants and/or tissue expanders. The most common presentation of these patients is late seroma, with some patients presenting with mass, tumor erosion, or lymph node metastasis. A recent review of the world literature on this entity include the following: (1) 173 cases were documented, (2) no cases were found in patients with documented smooth devices only (although this remains controversial, as the data in many cases are incomplete), (3) there may be an associated genetic predisposition as suggested for cutaneous T-cell lymphoma, and (4) the cause is likely multifactorial.
Bacterial biofilm is thought to be an inciting factor for the development of both breast-implant related ALCL and Non-Tumor related capsule contractures. The capsules from patients with tumor had significant presence of Gram-negative bacteria (Ralstonia species) compared to nontumor capsules (Staphylococcus species). Such data may support the bacterial induction model, as there are also other types of implant-associated lymphomas.
A 45-year-old woman who is obese is considering unilateral mastectomy and reconstruction of the left breast because of invasive ductal carcinoma. Which of the following patient characteristics is associated with the lowest risk for complications from a nipple-sparing mastectomy?
A) BMI of 41 kg/m2
B) Grade III ptosis of the breast
C) Nipple retraction
D) Tumor distance from nipple of 5 cm
E) Tumor size of 6 cm
The correct response is Option D.
Nipple-sparing mastectomy is increasing in popularity. To decrease the risk for surgical complications as well as oncologic complications, smaller tumors located further from the nipple in patients without morbid obesity or severe ptosis are considered better candidates for treatment with nipple-sparing mastectomy. Clinical involvement of the nipple, including retraction, would suggest that nipple-sparing mastectomy should not be performed.
References
Which of the following is the most likely chronic effect of post-mastectomy radiation therapy?
A) Desquamation
B) Dyspigmentation
C) Edema
D) Erythema
E) Ulceration
The correct response is Option B.
Radiation therapy induces tissue injury that can be categorized as acute or chronic. The spectrum of acute injury includes erythema, edema, desquamation, hyperpigmentation, and ulceration, ranging from mild to severe. Acute radiation dermatitis occurs in upward of 85% of treated patients. Chronic injury involves skin atrophy, dryness, telangiectasia, dyspigmentation, and dyschromia. In the breast, it leads to chronic fibrosis of the skin and subcutaneous tissues. This fibrosis and surrounding injury can lead to pain and restricted movement of the arm. The chronic changes from radiation can take months to years to fully manifest.
A 43-year-old woman who is BRCA-positive is scheduled to undergo bilateral mastectomy. Tissue expander–based reconstruction is planned. Which of the following is the optimal duration of antibiotic prophylaxis for this patient?
A) No preoperative antibiotic
B) One preoperative antibiotic dose and another dose during skin closure
C) One preoperative antibiotic dose, followed by 24 hours of treatment while in the hospital
D) One preoperative antibiotic dose, followed by 24 hours of treatment while in the hospital and then discharge on oral antibiotics until drains are removed
E) One preoperative antibiotic dose, followed by 24 hours of treatment while in the hospital and then maintenance on oral antibiotics until tissue expanders are exchanged
The correct response is Option C.
The overall complication rate in breast reconstructive surgery is as high as 60%. Infection rates can exceed 20%, much higher than in clean elective surgery. The CDC guidelines suggest only 24 hours of peri-operative antibiotics beginning thirty minutes prior to skin incision. However, not all plastic surgeons agree with this. A 2013 meta-analysis found when comparing combined patient cohorts receiving no antibiotics, antibiotics for less than 24 hours, and antibiotics for greater than 24 hours, the average infection rates were 14.4, 5.8, and 5.8%, respectively. This demonstrated that the administration of antibiotics made a difference, however duration beyond 24 hours did not.
A study was published in 2013 evaluating the difference in surgical site infection between two different prophylactic antibiotic durations (24 hours and until drain removal). In this prospective, randomized, controlled non-inferiority trial, 24 hours of antibiotics is equivalent to extended oral antibiotics for surgical-site infection in tissue expander immediate breast reconstruction patients.
A 45-year-old woman comes to the office for consultation about immediate bilateral breast reconstruction of a right-sided tumor measuring 2.5 cm. Biopsy reveals a HER-2/neu negative invasive ductal carcinoma without lymphovascular invasion. The patient requests nipple-sparing mastectomy. Physical examination shows a palpable mass is located in the right upper outer quadrant approximately 1.5 cm from the nipple-areola complex and is freely mobile. There is no lymphadenopathy on exam. Based on current literature, which of the following best describes this patient’s candidacy for the requested procedure?
A) Good candidate based on current presentation
B) Not a candidate because of lymph node status
C) Not a candidate because of tumor location
D) Not a candidate because of tumor pathology
E) Not a candidate because of tumor size
The correct response is Option C.
Nipple-sparing mastectomy or total skin-sparing mastectomy is becoming an increasingly popular choice for women because of the excellent cosmetic outcomes and the ability to save the nipple-areola complex that may provide psychological benefits with increased patient satisfaction as well. Nipple-sparing mastectomy appears to be oncologically safe with low risks of cancer recurrence in the literature thus far. However, there has been little long-term follow-up, so this approach is still somewhat controversial because the oncologic safety and locoregional recurrence have not been examined definitively. Although certain centers are pushing the envelope regarding the use of this technique in a wide range of patients, the current literature supports the following exclusion criteria:
A. Tumor size greater than 5 cm B. Tumor location less than 2 cm from the nipple C. Evidence of axillary disease D. Tumor involvement on retroareolar biopsy E. Lymphovascular invasion, human epidermal growth factor receptor-2 positivity, and/or HER-2/neu positivity on biopsy
The current patient’s tumor was found to have a tumor-to-nipple distance of 1.5 cm which is a relative contraindication to nipple-sparing mastectomy in this case.
A 54-year-old woman undergoes bilateral immediate tissue expander–based breast reconstruction. BMI is 36 kg/m2. On postoperative day 10, examination shows bilateral breast erythema; empiric antibiotics are started. In addition to Staphylococcusspecies, which of the following bacteria should be treated as the next most likely pathogen?
A) Bacteroides fragilis
B) Enterococcus faecalis
C) Mycobacterium marinum
D) Pasteurella multocida
E) Pseudomonas aeruginosa
The correct response is Option E.
After Staphylococcus aureus and S. epidermidis, Pseudomonas aeruginosa is among the the next most common sources of breast infections. It is common in hospitalized or immunocompromised patients, as well as patients with foreign body devices such as catheters or implants. It is a gram negative rod, and common antibiotic treatments include advanced β-lactams (piperacillin, ceftazidime), carbapenems, quinolones, and aminoglycosides. Dual coverage is often recommended in severe infections. In the case of breast implant infections, if there is not rapid improvement on antibiotic therapy, or if significant systemic symptoms develop (vital sign instability, high white blood cell count, fever, renal impairment), then surgical washout and device removal is mandatory. In patients without systemic symptoms, wash out and new implant placement can be an option in carefully selected and counseled patients. Other breast pathogens include Escherichia coli, Propionibacterium, and Corynebacterium.
More than 300,000 breast implant procedures are performed each year in the United States. In reconstructive cases, the infection rate averages 6% and the explantation rate 3% (range, 1.5 to 8%). Preventative measures include proper patient selection, preoperative MRSA management when carriers are suspected, routine presurgery chlorhexidine washes, proper antibiotic timing presurgery and continuation of antibiotics in implant reconstruction cases for at least 24 hours (though the optimal treatment duration has not yet been determined).
None of the other bacteria listed are common in breast infections, though all are common pathogens. Bacteroides are anaerobic gram-negative rods that are common in gut flora and feces.
Enterococcus faecalis is a frequent cause of nosocomial infection, with a high prevalence of multi-drug resistance. It is a gram-positive coccus, and is not commonly seen in breast surgery patients as it primarily colonizes the digestive tract.
Mycobaterium marinum is a rare pathogenic cause of hand infections from injuries that occur in aquatic environments.
Pasteurella multocida is a frequent cause of animal bite infections, particularly from cats and dogs.
A 62-year-old woman is evaluated because of a new 2 × 2-cm open area near her left axillary fold. Medical history is significant for left breast cancer previously treated with bilateral mastectomies, left axillary node dissection, and adjuvant chemoradiation 10 years ago. A photograph is shown. She has been compliant with postoperative oncologic surveillance and has had no recent trauma. Which of the following underlying conditions is most likely responsible for her current presentation?
A) Empyema with spontaneous drainage
B) Lymphedema drainage tract
C) Osteoradionecrosis of the underlying rib(s)
D) Recurrent breast cancer
E) Skin ulceration from intertriginous shearing forces
The correct response is Option C.
The effects of ionizing radiation are permanent and may present either acutely or in delayed fashion, even years after the original radiation insult. The mechanism of injury from this radiation is through free radical production which, in turn, directly damages the DNA. In the acute period, the effects of radiation may manifest themselves as erythema and edema of the skin, vasodilation with endothelial edema, and lymphatic obliteration. This eventually leads to capillary thrombosis and subsequent inadequate tissue oxygenation. Over time, nonhealing ulcers can spontaneously develop, sometimes years later.
Although recurrent cancer is always a concern in patients with a personal history of cancer, proper, regular, and thorough surveillance can often detect recurrences early, especially in compliant patients. Most recurrences occur within the first 5 years.
Abscesses usually present initially with pain, erythema, and localized fluctuance, and often with associated fever and/or malaise. Spontaneous necessitation to the skin would also result in purulent drainage.
Lymphedema can be a chronic condition after mastectomy and axillary node dissection, and is usually manifested as generalized edema of the ipsilateral upper extremity. Sinus tract formation is rare.
Intertriginous shearing would most often present as superficial epidermal loss with possible superinfection with yeast due to moisture.
Which of the following factors is most likely to lead to a patient undergoing breast reconstruction after mastectomy?
A) BRCA1/BRCA2 status
B) Insurance coverage through Medicaid
C) Living close to a reconstructive surgeon
D) Patient age
E) Residence in the southeastern United States
The correct response is Option C.
Several large population-based studies in different regions of the United States show that provision of breast reconstruction is not uniform among all mastectomy patients. The two biggest factors are geographic distance from reconstructive surgeons and insurance status. Patients who live farther away from providers of reconstruction and those uninsured or with Medicaid have a much lower incidence of reconstruction compared to the overall cohorts. Most studies also show BRCA positive and younger patients tend to have a higher incidence of bilateral reconstruction.
A 48-year-old woman is evaluated for bilateral microsurgical breast reconstruction. Compared with the deep inferior epigastric perforator (DIEP) flap, the superficial inferior epigastric artery (SIEA) flap places the patient at a greater risk for which of the following complications?
A) Abdominal bulge
B) Donor site dehiscence
C) Fat necrosis
D) Flap failure
E) Umbilical necrosis
The correct response is Option D.
Several comparative studies have reported a higher incidence of anastomotic thrombosis and failure with the superficial inferior epigastric artery (SIEA) flap than with flaps based on the deep inferior epigastric artery (DIEA). These failure rates range from 7.35 to 14%. Most of these failures were arterial in nature. Since SIEA flaps do not require an incision into the anterior rectus sheath or rectus muscle, bulges do not occur. Reported fat necrosis rates are similar between SIEA and DIEA flaps. There is no evidence for a difference in donor site dehiscence or umbilical necrosis rates.
Which of the following is most commonly associated with alloplastic breast reconstruction in the setting of adjuvant radiation therapy?
A) Decreased rates of implant rupture
B) Decreased rates of seroma
C) Increased patient satisfaction
D) Increased risk for capsular contracture
The correct response is Option D.
Alloplastic breast reconstruction increases the risk for capsular contracture in the setting of adjuvant radiation therapy. It can also increase the risks for seroma, wound healing complications, and infections. Radiation would not decrease the rates of implant rupture and would not increase patient satisfaction.
A 65-year-old woman with a history of left mastectomy for breast cancer 10 years ago undergoes biopsy of a suspicious lesion of the right breast found on a recent mammogram. Examination of the biopsy specimen confirms a right breast carcinoma. This lesion most likely originated from which of the following structures?
A) Adipose tissue
B) Areolar skin
C) Lactiferous duct
D) Lymph node
E) Pectoralis major muscle
The correct response is Option C.
Women who were previously treated for breast cancer are at increased risk for development of a metachronous lesion of the contralateral breast. Cancers of the breast are typically adenocarcinomas, arising from the glandular tissue such as the ducts or lobules. Paget disease of the breast would involve the areolar skin but is fairly uncommon. Sarcomas arising from the connective tissue (such as adipose or muscle) are also rare. Breast adenocarcinomas do not originate from lymphatic tissue.
A 48-year-old woman undergoes immediate unilateral breast reconstruction with a free deep inferior epigastric artery perforator (DIEP) flap. At the conclusion of the procedure, the flap skin paddle is noted to have venous congestion. Upon reexploration, the venous anastomosis appears patent with venous outflow detected by handheld pencil Doppler evaluation, but the flap continues to have venous congestion with brisk capillary refill. Which of the following is the most appropriate next step in management?
A) Apply leeches postoperatively
B) Loosely re-inset the flap and monitor closely
C) Perform a second venous anastomosis using the superficial inferior epigastric vein
D) Perform a second venous anastomosis using the vena comitans
E) Revise the venous anastomosis using a hand-sewn technique
The correct response is Option C.
Preservation of the superficial inferior epigastric veins (SIEV) during flap harvest is a useful preventive measure in microsurgical free tissue transfer operations. These veins can serve as important lifeboats to augment venous outflow in the setting of venous congestion. Typically, if a free flap demonstrates venous congestion, the inset should be taken down and the pedicle, recipient vessels, and anastomoses should be interrogated. Simple issues, such as mechanical compression or twisting of the vein, should be ruled out. Next, the SIEV should be inspected. If engorged, the flap is likely reliant on superficial outflow, and this vein should be connected to a recipient vessel to augment the venous outflow of the flap. Options for recipient veins include an anterograde branch on the pedicle vena comitans, or in a retrograde fashion to the vena comitans that was not used in the initial set of anastomoses.
In this case scenario, the flap continued to demonstrate venous congestion intraoperatively. This makes it unlikely that tension or pressure from the inset of the flap was causing the venous outflow obstruction. Furthermore, leech therapy is not indicated for a free flap with global venous congestion.
The venous coupling device is safe and effective for the anastomosis of veins in DIEP flap surgery. It has not been associated with patency rates that are different from hand-sewn anastomoses. The coupling device, however, has been shown to reduce the microsurgery time.
The use of one or two veins in microsurgical free tissue transfer is a topic that has been debated for several years. While some studies indicate that the use of two venous connections may reduce the velocity of blood flow across the anastomosis, there is not sufficient data to support differences in flap outcomes or thrombotic events. Therefore, the routine use of a second vein is largely up to surgeon preference.
A 43-year-old woman undergoes the second stage of tissue expander–based breast reconstruction. Exchange of the tissue expander for a smooth round silicone implant is planned along with a superior capsulotomy and fat grafting to the upper pole for contour improvement. Which of the following is an increased risk associated with fat grafting to the breast in this patient?
A) Anaplastic large cell lymphoma
B) Benign lesions
C) Hypopigmentation
D) Infection
E) Recurrent breast cancer
The correct response is Option B.
Autologous fat grafting is a widely accepted technique in breast reconstruction. A large systematic review recently confirmed the oncologic safety of this technique but did report a significant incidence of benign lesions including cysts and calcifications. Fat grafting is not associated with an increased risk of recurrent breast cancer, infection or hypopigmentation.
A 36-year-old woman with invasive ductal carcinoma of the left breast comes to the office to discuss options for immediate breast reconstruction. Examination shows that the tumor is positive for estrogen receptor (ER) and progesterone receptor (PR) expression. Family history is negative for breast and ovarian cancer, and genetic testing shows no abnormalities. Bilateral mastectomy is planned. Which of the following outcomes is most likely in this patient following contralateral prophylactic mastectomy of the right breast?
A) Decreased number of anticipated overall operations
B) Decreased risk of recurrence of the known cancer
C) Increased cure rate for her known cancer
D) Increased possibility of future breast-feeding
E) Increased risk of surgical site complications
The correct response is Option E.
Contralateral prophylactic mastectomy (CPM) has become increasingly common in recent years. Women who are at higher than average risk of developing breast cancer may have a clear oncologic benefit from CPM in terms of risk reduction. This would include women who are carriers of high-risk genetic mutations such as BRCA1 and BRCA2, women with a strong family history of breast cancer, and young women with high risk of aggressive tumors. However, for women with average risk of contralateral breast cancer (2 to 6% over 10 years), studies have not supported an oncologic benefit to CPM, attitudes of the lay public and media attention notwithstanding.
Since the surgeries of each breast, involving both mastectomy and reconstruction, are largely (although not completely) independent of one another, the risk of surgical complications to one side or the other is nearly additive, resulting in an approximate doubling of those risks.
CPM has not been shown to improve the cure rate for the known cancer treated with therapeutic mastectomy.
CPM has not been shown to reduce risk of recurrence for the known cancer on the primary side.
CPM would not be expected to decrease the number of anticipated operations. Given the increased likelihood of complications, one may reasonably expect the same number of operations or greater (for treatment of complications), but not fewer.
Removal of both breasts eliminates the ability to breast-feed in the future.
A 54-year-old woman with breast cancer undergoes a skin-sparing mastectomy with tissue expander reconstruction. Adjuvant chemotherapy and subsequent radiation therapy have been recommended. Chemotherapy proceeds during tissue expansion. Radiation may be performed either before or after the implant exchange procedure. When compared with radiating the permanent implant, radiating the tissue expander is most likely to increase the risk of which of the following?
A) Cancer recurrence
B) Capsular contracture
C) Device rupture
D) Explantation
E) Radiation dermatitis
The correct response is Option D.
Cordeiro et al. updated the largest series of women undergoing two-stage implant breast reconstruction who require postmastectomy radiation. The authors found that radiating the tissue expander, as opposed to the permanent implant, increased the rate of reconstructive failure by 46%. However, aesthetic results were better and capsular contracture was less frequent. There were no differences in patient-reported outcomes. This study confirmed the earlier findings of Nava et al. regarding reconstruction failure (explantation). There are no known differences in cancer recurrence between the two approaches discussed.
A 52-year-old woman comes to the office to discuss revision of breast reconstruction following mastectomy for breast cancer. She is undergoing adjuvant treatment with an agent that interferes with her body’s natural mechanisms that promote native breast growth, but she cannot remember its name. She is most likely being treated with which of the following agents?
A) Alkylating agent (cyclophosphamide)
B) Anthracycline (doxorubicin)
C) Aromatase inhibitor (anastrozole)
D) Platinum agent (cisplatin)
E) Taxane (paclitaxel)
The correct response is Option C.
Aromatase inhibitors such as anastrozole impair conversion of androgens to estrogens. Estrogens promote normal breast tissue growth as well as growth of many breast cancers. The other options (taxanes, anthracyclines, alkylating agents, and platinum agents) are all chemotherapeutic agents that do not particularly target hormones involved in normal breast growth mechanisms.
Improvement in which of the following is an advantage of nipple-areola complex reconstruction?
A) Breast feeding ability
B) Breast mound shape
C) Reactivity to touch
D) Satisfaction with reconstruction
E) Sexual sensation
The correct response is Option D.
Satisfaction with reconstruction, quality of life, and feeling of completeness with reconstruction have all been shown to be linked to nipple and/or areola reconstruction. The reconstruction does not restore nipple function; therefore, breast feeding, sexual sensation, and reactivity to touch are not accomplished with nipple and/or areola reconstruction. Often the nipple reconstruction, if using local tissue techniques, may actually flatten the anterior aspect of the breast and is not thought to positively impact the breast mound shape.
A 75-year-old woman is evaluated after undergoing bilateral autologous breast reconstruction with deep inferior epigastric artery perforator (DIEP) flaps 2 days ago. The patient had been recovering well until this morning, when she developed acute respiratory insufficiency with hypoxia, tachycardia, and tachypnea. Pulmonary embolism is suspected, and pulmonary CT angiography has been ordered. Baseline creatinine level is 1.1 mg/dL. Which of the following steps should be taken to prevent contrast-induced nephropathy in this patient?
A) Hydration with hydroxyethyl starch (colloid)
B) Hydration with 0.9% saline
C) No preventive measures are needed
D) Pretreatment with the antioxidant N-acetylcysteine
E) Pretreatment with 0.9% saline and diphenhydramine
The correct response is Option B.
Although the risk of contrast-induced nephropathy (CIN) is overall relatively low, geriatric patients are at higher risk for this complication secondary to their high prevalence of risk factors for renal dysfunction. In this patient population, even normal laboratory creatinine concentrations are not always indicative of normal glomerular filtration rate (GFR), and every effort should be made to prevent the development of CIN. Important prophylactic strategies to avoid this adverse effect include optimization of fluids and avoidance of dehydration, use of non-ionic contrast media, and avoiding repeated exposure to contrast at close intervals.
This geriatric patient should be well hydrated prior to undergoing exposure to this high-contrast study. Minimizing fluid and performing no intervention will increase the patient’s risk of developing CIN even with a normal creatinine concentration. Antioxidants such as N-acetylcysteine, vasodilators such as dopamine, and colloid solutions such as Hespan have not proven to be beneficial in preventing renal dysfunction. Pretreatment with 0.9% saline and diphenhydramine is used in patients who have allergies to the contrast dye to minimize the allergic reaction and plays no role in preventing CIN.
A 55-year-old woman comes to the office for a second opinion because she is displeased with the results of a recent bilateral mastectomy and breast reconstruction with 800-mL high-profile silicone implants. A photograph is shown. BMI is 35 kg/m2. She repeatedly shows pictures of models with augmented breasts and says that she wants her breasts to be “perkier.” She requests augmentation/mastopexy. Which of the following is the most appropriate next step in management?
A) Augmentation/mastopexy
B) Implant exchange
C) Mastopexy
D) Reassurance
E) Referral to a psychiatrist
The correct response is Option D.
The most reasonable approach in this patient is to offer reassurance and reset her expectations. A patient with a BMI of 35 kg/m2 who undergoes mastectomy and implant reconstruction will never look like a model with augmented breasts. This patient clearly has misguided expectations. Any surgical intervention is unlikely to produce the result she is looking for, when in fact she has a very acceptable result as is. Referral of this patient to a psychiatrist will likely upset the patient and undermine her trust.
A 48-year-old woman undergoes radical resection of the left breast, left hemisternectomy, four-rib resection, and visceral pleurectomy because of invasive inflammatory breast cancer extending through the thoracic wall into the mediastinum and chest. Examination of specimens obtained from intraoperative frozen section biopsies shows no residual disease. Postoperative adjuvant chemotherapy and radiation therapy to the area are planned. An intraoperative photograph of the 17 × 17-cm defect is shown. Which of the following is the most appropriate technique for soft-tissue reconstruction?
A) Left latissimus muscle flap with skin graft
B) Omental flap with skin graft
C) Left rectus turnover flap with skin graft
D) Reverse abdominoplasty flap
E) Right TRAM flap
The correct response is Option E.
The most appropriate option for this patient would be a right TRAM flap. The defect encompasses a composite defect of the left side of the sternum, including the left internal mammary artery, four contiguous ribs, and the entire left breast. The question specifically asks for soft-tissue thoracic reconstruction. The analysis of the defect yields a very large soft-tissue requirement. Given this, the most logical choice of flaps to provide this amount of soft tissue on a reliable pedicle would be a right (contralateral) TRAM flap. Furthermore, this flap could also be shaped to provide a breast mound versus all the other choices.
A left latissimus muscle flap with skin graft is not the optimal choice as it would not provide sufficient soft-tissue coverage with its associated skin paddle without undue donor site morbidity in this particular patient with a large defect that spans parasternal and lateral chest wall. As a muscle-only flap with skin graft, however, it may be considered as a backup option in case of primary flap failure.
An omental flap with skin graft is an option for reconstruction of this defect; however, it would not be the most appropriate option in this case as it would necessitate an otherwise unnecessary intra-abdominal procedure and would not reshape a breast mound. It has been shown, however, to be optimal in contaminated areas due to its associated lymphatic vessels and nodes associated with its pedicle, so in different circumstances, this may be a preferred choice.
A left rectus turnover flap with skin graft would not be a good option for two reasons: the left internal mammary artery has been harvested, thereby compromising the superior epigastric vessel on which this flap would be based; and it would not cover the entirety of the defect.
A reverse abdominoplasty flap would not be able to reach the full superior extent of the defect.
A 74-year-old woman comes to the office because of a 2-month history of increasing soreness over the left lateral chest wall. History includes bilateral radical mastectomy and adjuvant radiation to the left chest 30 years ago because of left-sided breast cancer. On examination, a small, nonhealing 1 × 2-cm wound is visible in the subaxillary region within an area of dense fibrotic skin. A photograph is shown. Which of the following is the most appropriate next step?
A) Biopsy of the nonhealing wound
B) Coverage with a left latissimus muscle flap and skin grafting
C) LHyperbaric oxygen treatment
D) MRI of the chest wall
E) Oral administration of antibiotics for 7 days
The correct response is Option A.
This patient’s presentation is consistent with late radiation tissue injury (LRTI), which occurs in 5 to 15% of long-term cancer survivors who have received radiation and can occur months to years (even decades) after treatment. It can vary significantly with age, dose, and site of treatment. Characteristics include progressive tissue deterioration secondary to decreased vascularity followed by replacement of normal soft-tissue architecture by dense fibrotic tissue until there is insufficient oxygen delivery to sustain normal function. When LTRI of the chest wall progresses to skin breakdown and ulceration, as has happened in this patient, a biopsy is always required to rule out recurrence of the primary tumor or a radiation-induced squamous cell carcinoma or soft-tissue sarcoma.
Hyperbaric oxygen therapy has been proposed as a treatment modality that can improve tissue quality and prevent tissue breakdown in irradiated areas. While most data on this relate to treatment of osteoradionecrosis of the mandible, there have been some reports of its use on the chest wall after irradiation due to breast cancer. However, the question specifically asks for the most appropriate next step, which would be biopsy rather than hyperbaric oxygen therapy.
The principles of management once malignancy has been ruled out include debridement of necrotic tissues (including ribs) and reconstruction with well-vascularized flaps. In this case, a left latissimus muscle flap and skin graft was used for reconstruction after aggressive debridement. No alloplastic material was placed or thoracic cage reconstruction performed. This is common in these types of patients as excessive fibrosis caused by the radiation to the chest wall prevents loss of respiratory efficiency through paradoxical motion.
CT scan or MRI may be useful in evaluating the size, extent, and nature of the problem, but does not take priority over tissue biopsy.
The redness that is visualized on the patient’s skin in the case is related to post-radiation changes and telangiectasias, which are common in LTRI, and is not infection. Therefore, antibiotics would be unnecessary.
A 12-year-old girl with Beckwith-Wiedemann syndrome develops profound breast enlargement at the onset of puberty. Physical examination shows two distinct masses in the right breast and severe hyperplasia consuming the left breast. A photograph is shown. Which of the following is the most appropriate surgical management?
A) Hormone suppression therapy
B) Right lumpectomies; left mastectomy with skin reduction with application of nipple as skin graft
C) Right simple mastectomy; left mastectomy with skin reduction with application of nipple as skin graft
D) Right simple mastectomy; left simple mastectomy with sentinel lymph node biopsy
E) Right total mastectomy; left modified radical mastectomy
The correct response is Option B.
Epithelial hyperplasia is a benign pathological process. Therefore, modified radical mastectomy or sentinel lymph node biopsy would not be indicated in the absence of cancer. Mastectomy on the right is not indicated because the masses are discrete and separate from the normal breast parenchyma. As such, a viable breast mound can be preserved in this 12-year-old girl. Because of the expansive nature of her hyperplasia on the left, skin reduction is required to ensure smooth contour of her skin flaps. The nipple may be spared because of the benign disease. Reconstruction can be performed in a delayed fashion after development is complete. An adjustable expander/prosthesis can also provide a reasonable breast mound until definitive reconstruction is performed.
Hormone suppression therapy may temporarily slow the growth of the hyperplasia but could adversely affect this child’s normal development. It would not comprise definitive management.
A 16-year-old girl is brought to the office by her parents because she has had worsening pain in the right breast (shown) for the past eight months. Ten years ago, she sustained a full-thickness burn to the back, right chest, and abdomen requiring excision and split-thickness skin grafting. Physical examination shows contracture of the scar and lateral expansion of the breast. After release of the burn scar contractures, a defect of 200 cm2 is created. Which of the following is most appropriate for coverage of this defect?
(A) Dermal regeneration template (Integra)
(B) Latissimus dorsi musculocutaneous flap
(C) Meshed split-thickness skin graft
(D) Nonmeshed thin split-thickness skin graft
(E) Z-plasty release of the constricted scar
The correct response is Option A.
The patient described is suffering from pain caused by a developing breast that is constricted under a nonexpanding split-thickness skin graft placed at the time of the burn excision. The burn scar contractures are first released to allow expansion of the underlying breast. The decision for coverage material is then based on what will most likely permit further expansion of the breast.
Dermal regeneration template (Integra) has been shown to allow secondary expansion and is the most appropriate choice for the scenario described. The wound is covered with an expandable dermal layer, which is then covered again by a split-thickness skin graft, leaving a minimal donor scar.
A Z-plasty would be inadequate to release this large scar.
Full-thickness skin grafting would allow greater breast expansion and less secondary burn scar contracture, but a graft of the size needed would be difficult to obtain.
A latissimus dorsi flap would not be the best option for the patient described because she has a history of burns on the back. Also, a latissimus dorsi flap would be bulky, and the patient described does not require additional volume.
Nonmeshed thin split-thickness skin grafting would give a superior aesthetic result compared with meshed split-thickness skin grafting; however, both would result in secondary burn scar contracture, which would not allow further expansion of the breast.
A 45-year-old woman who underwent reconstruction of the left breast with a TRAM flap followed by radiation two years ago is evaluated for a second reconstruction procedure on the left breast (shown). She requests that only reconstruction with her own tissues be performed and is opposed to surgery of the right breast to restore symmetry. On physical examination, the breast is shrunken and firm. After removal of the unsalvageable left breast, which of the following is the most appropriate reconstruction technique at this time?
(A) Deep inferior epigastric perforator (DIEP) flap
(B) Free TRAM flap
(C) Latissimus dorsi myocutaneous flap
(D) Superior gluteal artery perforator (SGAP) flap
(E) Thoracoepigastric flap
The correct response is Option D.
When there is near-total loss of a TRAM flap for breast reconstruction, it is important that a second breast reconstruction procedure be successful, with special consideration for safety. When there is insufficient lower abdominal tissue for tissue expansion and transfer of a second flap, neither a free TRAM flap nor a deep inferior epigastric perforator (DIEP) flap recruiting soft tissue in the same lower abdominal areas is an option. A latissimus dorsi myocutaneous flap is a reliable source of autogenous tissue; however, considering the size of the contralateral breast in this patient, a latissimus dorsi myocutaneous flap would need to be supplemented by a permanent expander implant to provide sufficient volume. A staged breast reconstruction with tissue expander would also require permanent implantation of a prosthesis upon completion of the expansion process. A gluteus free flap is considered when the latissimus dorsi flap is not sufficient or available and the patient requests autogenous tissue breast reconstruction. The free sensate superior gluteal artery perforator (SGAP) flap is a free sensate flap based on the superior gluteal artery perforator. It has an abundance of adipose tissue (specimens up to 760 g), even in thin patients, a relatively long vascular pedicle, a discrete scar, improved projection compared with the DIEP and TRAM flaps, and preservation of the entire gluteus maximus muscle with extremely low donor site morbidity.
Six hours after undergoing breast reconstruction with a free TRAM flap, a 35-year-old woman has swelling of the reconstructed area and bluish discoloration of the skin. A photograph is shown above. Capillary refill time is increased. Findings on Doppler ultrasonography of the flap are within normal limits.
Which of the following is the most appropriate next step in management?
(A) Fluid resuscitation
(B) Anticoagulant therapy
(C) Release of sutures and observation
(D) Operative exploration
The correct response is Option D.
This 35-year-old woman who underwent breast reconstruction now exhibits signs of venous outflow obstruction, including increased capillary refill time, dark or bluish discoloration of the skin, and swelling of the affected area. In addition, complete venous obstruction does not always manifest as abnormal findings on Doppler ultrasonography, and the Doppler signal may indeed fall within normal limits in many affected patients. Therefore, in the presence of these clinical signs, the only appropriate option is to perform repeat operative exploration.
Fluid resuscitation and anticoagulant therapy are not appropriate treatment of venous obstruction in patients who have undergone free tissue transfer. In the same way, release of the sutures will not resolve the obstruction.
