Breast Reconstruction Flashcards
An otherwise healthy 52-year-old woman is scheduled to undergo bilateral breast reconstruction with abdominal perforator flaps. She does not smoke cigarettes. Which of the following is the most appropriate antibiotic prophylaxis regimen?
A) Preoperative antibiotics
B) Preoperative chlorhexidine bath
C) Preoperative and intraoperative antibiotics
D) Preoperative, intraoperative, and postoperative antibiotics for 7 days
E) Preoperative, intraoperative, and postoperative antibiotics until all drains are removed
C) Preoperative and intraoperative antibiotics
A single dose of preoperative antibiotic intravenously is appropriate for short procedures; however, therapeutic levels of antibiotic should be maintained throughout the lengthy surgery described.
Continued administration of prophylactic antibiotics for 7 days following surgery or until drains are removed has not been proven to reduce the incidence of surgical site infections. This regimen also promotes drug resistance and adverse patient reactions.
For a healthy patient undergoing a lengthy autologous breast reconstruction, the most appropriate regimen of antibiotic prophylaxis consists of:
For a healthy patient undergoing a lengthy autologous breast reconstruction, the most appropriate regimen of antibiotic prophylaxis consists of a preoperative dose of intravenous antibiotic and intraoperative antibiotics to maintain therapeutic levels during operation and, at most, a few hours after closure
A 52-year-old woman with breast cancer undergoes right mastectomy and reconstruction with a free transverse rectus abdominis musculocutaneous (TRAM) flap. The procedure is uneventful. In the recovery room, the patient’s husband says that she has been smoking one pack of cigarettes daily up to the day of surgery. Which of the following postoperative complications is most likely to occur? A) Flap hematoma B) Mastectomy skin loss C) Microvascular thrombosis D) Partial flap loss E) Superficial infection
B) Mastectomy skin loss
Smoking vs risks that have been increased vs unchanged
Patients who smoke cigarettes and who undergo breast reconstruction with a free flap have a higher rate of mastectomy skin loss. In addition, they havea high rate of donor site abdominal flap necrosis, umbilical necrosis, and hernias. There is no increase in microsurgical complications, flap-related complications (partial flap loss or fat necrosis), infections, or hematomas
Patients should stop smoking how long before breast reconstruction?
Recommendations are for patients to stop smoking at least 4 weeks prior to breast reconstruction. Patients who quit smoking prior to this period have a lower risk of perioperative complications when compared to active smokers
A 53-year-old woman is referred for consultation regarding breast reconstruction following mastectomy. Autologous breast reconstruction options are discussed. Which of the following is an advantage of the pedicled transverse rectus abdominis musculocutaneous (TRAM) flap over the free TRAM flap?
A) Decreased complications in patients with a history of smoking
B) Decreased incidence of complete flap loss
C) Decreased risk of abdominal hernia
D) Decreased risk of fat necrosis
E) Ease of insetting and flap shaping
B) Decreased incidence of complete flap loss
Pros/Cons of peddled TRAM
The pedicled TRAM flap is characterized by a shorter operative time and a decreased risk of complete flap loss when compared to the free flaps. However, the pedicled TRAM flap shows a higher incidence of fat necrosis with partial flap loss, as well as an increased length of stay.
Benefits of free flaps over pedicled for breast reconstruction
Free flaps offer ease of flap shaping and insetting, as well as a decreased risk of abdominal hernia and abdominal wall weakness. Free flaps are more suitable for patients who are diabetic, are overweight, or smoke cigarettes.
A 45-year-old woman with a T2 N0 M0 invasive ductal carcinoma in the inferior pole of the left breast is scheduled to undergo segmental mastectomy followed by radiation therapy. She currently wears a size 36E brassiere and wants to have any cup size from a C to D. After segmental resection of the tumor, which of the following procedures is most likely to yield the best cosmetic result in this patient?
A) Bilateral reduction mammaplasty
B) Primary closure of the left breast and reduction mammaplasty of the right breast
C) Reconstruction of the left breast with a latissimus dorsi musculocutaneous flap and reduction mammaplasty of the right breast
D) Reconstruction of the left breast with a transverse rectus abdominis musculocutaneous flap and mastopexy of the right breast
E) A single-stage breast reconstruction with placement of a silicone prosthesis in the left breast and reduction mammaplasty of the right breast
A) Bilateral reduction mammaplasty
In a patient with large breasts, in whom a partial mastectomy is required, reduction mammaplasty is an appropriate management. This procedure will potentially relieve symptoms of macromastia, reduce the amount of breast tissue present in both breasts, and offer the best aesthetic outcome.
A 46-year-old woman with ductal carcinoma in situ is scheduled to undergo right mastectomy. Immediate reconstruction with a tissue expander and acellular dermal matrix (ADM) is planned. Which of the following is an expected outcome with use of ADM?
A) Decreased formation of seroma
B) Decreased incidence of hematoma
C) Decreased risk of infection
D) Increased capsule contracture
E) Increased initial fill of the expander
E) Increased initial fill of the expander
ADM and initial fill of saline for an expander
According to Sbitany, et al, acellular dermal matrix (ADM) allows for a greater initial fill of saline. This potentially improves cosmetic outcome, as it better capitalizes on preserved mastectomy skin for reconstruction. Sbitany, et al, concluded that ADM-assisted prosthesis breast reconstruction has a safety profile no worse than that of complete submuscular coverage but offers the benefit of fewer expansions and the potential for more predictable secondary revisions.
Pros/cons of ADM and prosthetic reconstruction
ADM has enhanced prosthesis-based reconstruction and remains useful in immediate prosthetic breast reconstruction. It has been reported to decrease capsule contracture. It also allows for greater initial fill of saline, potentially improving cosmetic outcomes.
However, it has been found to have higher rates of postoperative seroma and infection.
A 42-year-old woman is evaluated because of an invasive cancer of the right breast. Which of the following best approximates the likelihood that this patient's cancer is associated with the BRCA1 or BRCA2 genes? A) 1% B) 10% C) 25% D) 40% E) 75%
B) 10%
Among familial breast cancers, _____ are considered hereditary
Among familial breast cancers, 5 to 10% are considered to be hereditary.
Breast cancer susceptibility genes
The breast cancer susceptibility genes (BRCA) belong to a class of genes known as tumor suppressors. In normal cells, BRCA1 and BRCA2 genes stabilize the DNA and prevent uncontrolled cell growth.
A woman’s lifetime risk of developing breast and/or ovarian cancer is greatly increased if she inherits a mutation on BRCA1 or BRCA2 genes.
BRCA-1 and -2 breast cancers occur in what age group?
BRCA1-and BRCA2-related breast cancers are often associated with estrogen receptor-negative tumors
BRCA-1 and -2 breast cancers are associated with estrogen receptor - _________ tumors
BRCA1-and BRCA2-related breast cancers are often associated with estrogen receptor-negative tumors
A 37-year-old woman comes to the office for consultation regarding left breast reconstruction after mastectomy to treat breast cancer. Chemotherapy and radiation therapy are planned postoperatively. She wears a size 34D brassiere. Height is 5 ft 6 in (168 cm), and weight is 160 lb (73 kg). BMI is 25.8 kg/m2. She does not want abdominal scars. Autologous reconstruction with a transverse musculocutaneous gracilis (TMG) flap is planned. Which of the following is a disadvantage of using a TMG flap for this patient's reconstruction? A) Difficulty of flap harvest B) High risk of donor site morbidity C) High risk of fat necrosis D) Small flap size E) Variable vascular anatomy
D) Small flap size
The size of a transverse musculocutaneous gracilis flap for breast reconstruction
The largest flap harvested in one large series weighed 420 g and measured 30 × 10 cm. The flap usually offers enough volume to reconstruct small-to mid-sized breasts.
The major advantages of a transverse musculocutaneous gracilis flap for breast reconstruction:
The major advantage of this flap as compared with other flaps, such as the gluteal flap or the perforator latissimus flap, is its constant vascular anatomy. Flap perfusion is always reliable, with low rates of fat necrosis and tissue similar in consistency with breast tissue. The donor scar is inconspicuous. The incision is comparable to incisions for a thigh lift and is well hidden. A distortion of the labia majorais typically not observed.
Functional morbidity after transfers myocutaneous gracilis flap harvest
functional donor-site morbidity after TMG flap harvest itself is low.
A 43-year-old Caucasian woman is referred to the office because of a mass on her right breast that has been rapidly growing for 8 weeks. Physical examination shows a 4.5-cm, freely movable mass in the right breast. No axillary adenopathy or nipple discharge is noted. Which of the following is the most likely nonepithelial neoplasm in this patient? A) Fibroadenoma B) Hamartoma C) Lipoma D) Phyllodes tumor E) Primary breast lymphoma
D) Phyllodes tumor
Most common non epithelial neoplasm of the breast
Phyllodes tumor
Phyllodes tumor
Phyllodes tumors represent about 1% of tumors in the breast; they are the most commonly occurring nonepithelial neoplasm of the breast. The tumor has a smooth, sharply demarcated texture and is generally freely movable. It is a relatively large tumor, with an average size of 5 cm
Hamartoma of the breast
Hamartomas of the breast are benign tumors composed primarily of dense fibrous tissues with variable amounts of fat and associated ducts.
Percent of phyllodes tumor that are benign / malignant
Eighty-five percent of phyllodes tumors are benign, and 15% are malignant.
Who gets phyllodes tumors?
There is no race predilection; occur almost exclusively in women
In young women under age 25 years, asymmetric, tender, and fibrocystic tissues usually point to:
In young women under age 25 years, asymmetric, tender, and fibrocystic tissues usually point to a fibroadenoma or circumscribed fibrocystic mass.
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
B) Right lumpectomies; left mastectomy with skin reduction with application of nipple as skin graft
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 ofthe 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.
Beckwith-Wiedemann syndrome
Congenital overgrowth disorder, w/ magroglossia, macrosomia, midline abdominal defects, ear creases or pits, and neonatal hypoglycemia; increased risk of childhood cancers, esp Wilms tumor, pancreatoblastoma, hepatoblastoma
A 60-year-old woman receives low-molecular-weight heparin (LMWH) 40 U subcutaneously 1 hour before undergoing breast reconstruction using a unilateral transverse rectus abdominis musculocutaneous (TRAM) flap. Weight is 185 lb (84 kg); BMI is 32 kg/m2. Which of the following is the most likely effect of the LMWH on perioperative risks in this patient?
A ) Decreased risk of flap failure
B ) Decreased risk of postoperative hematoma
C ) Decreased risk of pulmonary thromboembolism
D ) Increased risk of blood transfusion
E ) Increased risk of infection
C ) Decreased risk of pulmonary thromboembolism
The risk of developing DVT begins with:
As the risk of developing DVT begins with anesthesia induction, it is generally recommended that heparin therapy be started before surgery.
.. Out of concern for bleeding, some surgeons start heparin therapy in the early postoperative period.
A 53-year-old woman comes to the office because of ulcerated tissue 6 weeks after undergoing radiation therapy for breast cancer. She underwent mastectomy 1 year ago. Analysis of the radiated tissue is most likely to show an increase in which of the following? A ) Acute inflammatory response B ) Cytokines and growth factors C ) Neutrophil function D ) Tissue oxygenation E ) Vessel thrombosis
E ) Vessel thrombosis
Clinical appearance of acute radiation treatment
In acute radiation injury, the skin becomes erythematous and edematous with the dilation of fine blood vessels, endothelial edema, and lymphatic obliteration.
Skin perfusion in acute radiation injury
Although perfusion of the skin assessed with fluorescein injection appears normal, tissue oxygenation is inadequate.
Cells/ healing with acute radiation injury
Healing is impaired with slowed fibroblast proliferation and impairment of the acute inflammatory response. Fibroblast defects are the main problem in the inhibited healing of chronic radiation injury. Phagocytosis and bacteriocidal metabolic functions in neutrophils are also impaired.
A 45-year-old woman who has breast cancer comes to the office for consultation regarding bilateral breast reconstruction. Reconstruction using autologous abdominal tissue is considered. The risk of abdominal morbidity is discussed. Which of the following flap techniques is most likely to result in the lowest level of overall abdominal morbidity?
A ) Deep inferior epigastric artery perforator
B ) Free muscle-sparing transverse rectus abdominis musculocutaneous (TRAM)
C ) Free TRAM
D ) Pedicled TRAM
E ) Superficial inferior epigastric artery flap
E ) Superficial inferior epigastric artery flap
Which abdominal flap results in the lowest overall abdominal morbidity
The superficial inferior epigastric artery (SIEA) flap results in the lowest level of overall abdominal morbidity, as the technique used in harvesting this flap leaves the abdominal fascia intact.
Who can receive a superficial inferior epigastric artery flap?
SIEA vessels are only present in less than one third of patients, and only one half of those patients will have vessels of sufficient diameter to support a free tissue transfer.
Cons of the SIEA flap
The SIEA flap is associated with a higher frequency of total flap loss, in addition to a higher incidence of fatty necrosis
How can the DIEP flap cause abdominal wall morbidity?
The deep inferior epigastric artery perforator (DIEAP or DIEP) flap involves dissection of one or two (occasionally more) perforators through the rectus muscle to the inferior epigastric vessels. Although this technique does not include any rectus muscle or sheet/fasica within the flap itself, it does involve moderate-level trauma to those organs and can cause abdominal wall morbidity.
Pedicled TRAM morbidity vs other flaps
The general consensus remains thatin a bilateral reconstruction, pedicled TRAM flaps are associated with higher levels of overall abdominal morbidity (hernias, bulges, weakness, intolerance to exercise, etc) when compared with the use of MS free TRAM, DIEP, or SIEA flaps.
A 45-year-old man comes to the office for consultation regarding breast cancer after undergoing gene testing and learning that he is a carrier of the BRCA2 gene mutation. He has a strong family history of breast, prostate, and ovarian cancers. Which of the following best represents his lifetime risk for developing breast cancer? A ) 6% B ) 15% C ) 30% D ) 60% E ) 85%
A ) 6%
The relationship between male breast cancer and a deleterious ______ mutation has been well established:
The relationship between male breast cancer and a deleterious BRCA2 mutation has been well established. In the largest study to date, the lifetime risk of developing breast cancer in a BRCA2 male carrier is approximately 7%.
The relative risk of developing breast cancer is highest for men in their _________, and it ________ with increasing age
The relative risk of developing breast cancer is highest for men in their 30s and 40s, and it decreases with increasing age
A 21-year-old woman comes to the office for consultation regarding a palpable lump in the left breast that she first noticed 4 months ago. Phyllodes tumor of the breast is diagnosed. Which of the following is the most appropriate management at this time?
A ) Observation and incisional biopsy
B ) Neoadjuvant chemotherapy
C ) Local excision and annual surveillance
D ) Wide local excision and radiation therapy
E ) Mastectomy with immediate reconstruction
C ) Local excision and annual surveillance
Need for follow up of phyllodes tumor:
!nnual surveillance and follow-up is recommended because the pathologic appearance does not always predict the clinical behavior.
A 29-year-old woman who is positive for the BRCA1gene underwent bilateral mastectomies and immediate reconstruction with placement of tissue expanders. After completion of the second session of tissue expansion, she has severe pain in the chest wall. There is no evidence of hematoma or infection. Which of the following is the most appropriate next step in management?
A ) Administer pain medication
B ) Apply a warm compress to the breasts
C ) Plan for return to the operating room
D ) Reassure the patient
E ) Withdraw fluid from the tissue expander
E ) Withdraw fluid from the tissue expander
The patient’s pain immediately after expansion (or even in a slightly delayed manner) is indicative of ischemic tissue with poor oxygen tension.
Neural tissue has been shown to have the lowest tolerance to ischemia, hence in part explaining the pain. The most appropriate step in management is to withdraw enough fluid to relieve pain. This amount can be dramatically small at times; a few milliliters can correct the problem.
_______ issue has been shown to have the lowest tolerance to ischemia.
Neural tissue has been shown to have the lowest tolerance to ischemia
A 48-year-old woman undergoes skin-sparing mastectomy followed by immediate breast reconstruction with implantation of subpectoral prostheses. Which of the following best describes the resulting effect on pectoralis torque strength in this patient?
A ) Decreased on the operated side
B ) Decreased on the side of hand dominance
C ) Increased on the operated side
D ) Increased on the side of hand dominance
E ) No effect
A ) Decreased on the operated side
Effect of immediate subpectoral prosthetic breast reconstruction following skin-sparing mastectomy on pectoralis strength
The effect of immediate subpectoral prosthetic breast reconstruction following skin-sparing mastectomy on pectoralis function is a decrease in torque strength on the operated side by approximately 20% compared to the nonoperated side. This loss represents approximately half of the torque needed by healthy subjects over 50 years of age to rise from a chair and was therefore considered substantial (in the study showing this).
An 18-year-old man with Klinefelter syndrome is referred to the office because of overdeveloped breasts. Diagnostic workup testing is ordered. The likelihood of breast cancer is increased if testing shows which of the following results?
A ) Decreasedlevel of plasma follicle-stimulating hormone
B ) Decreased level of plasma luteinizing hormone
C ) High number of progesterone receptors in the mesenchymal breast tissue
D ) Increased level of plasma testosterone
E ) Low number of estrogen receptors in the mesenchymal breast tissue
C ) High number of progesterone receptors in the mesenchymal breast tissue
Breast size in patients with Klinefelter syndrome
Approximately one half of patients with typical Klinefelter syndrome (47,XXY) and one third of those with the mosaic variety (46,XY/47,XXY) develop gynecomastia.
Patients with Klinefelter syndrome who develop gynecomastia have:
Patients with Klinefelter syndrome and exhibiting gynecomastia have elevated plasma follicle-stimulating and luteinizing hormone levels, along with decreased plasma testosterone levels, suggesting a hormonal link with gynecomastia in the Klinefelter population.
Potential mechanism by which Patients w/ Klinefelter syndrome may develop breast neoplasms
The presence of estrogen and progesterone receptors in elevated concentration in patients with Klinefelter syndrome provides a potential mechanism by which these patientsdevelop breast neoplasms.
The absence of elevated estrogen and progesterone receptors in patients with idiopathic gynecomastia might help to clarify why these patients rarely develop breast malignancies.
Cause of most cases of gynecomastia
idiopathic
Hormones associated with development of gynecomastia
Studies have shown strong evidence for the estrogen-stimulating effects of breast tissue development and support for an inhibitory androgenic effect. Decreases in the androgen-to-estrogen ratio have also been associated with development of gynecomastia. No clear etiologic classification has been suggested based solely on hormonal influences.
A 36-year-old woman with a confirmed diagnosis of ductal carcinoma in situ is considering skin-sparing mastectomy and immediate reconstruction. The patient should be informed that her risk of developing recurrent ipsilateral breast cancer over the next four years is approximately which of the following? A ) 2% B ) 5% C ) 10% D ) 15% E ) 20%
A ) 2%
Recurrence rate of ductal carcinoma after skin sparing mastectomy over next four years
Several studies support skin-sparing mastectomy as an oncologically safe technique, based on the absence of breast ductal epithelium at the margin of the native skin flaps. A recurrence rate of less than 2% at 45 monthsis quoted in a study by Slavin and colleagues
A 32-year-old woman with multifocal ductal carcinoma in situ in her right breast is scheduled to undergo mastectomy. There is no family history of breast cancer. Results of testing for the BRCA gene mutation are negative. MRI of the left breast shows no abnormalities. A discussion is held with the patient about prophylactic mastectomy on the contralateral breast. Which of the following is the principal factor in the determination of whether to perform bilateral mastectomy? A ) Medical clearance B ) Need for radiation C ) Patient wishes D ) Reconstructive options E ) Tumor burden
C ) Patient wishes
In several studies, patients who underwent prophylactic mastectomy at the suggestion of the physician were generally more regretful than those who underwent the procedure following a patient-initiated discussion. The lack of perioperative emotional support also affected these patients. Lack of nipple sensation and inability to breast-feed are two factors leadingto patients’ regret about their decision
A 39-year-old woman is referred for consultation regarding reconstruction of the left breast two years after mastectomy for breast cancer. Implantation of a silicone prosthesis and reconstruction with a pedicled latissimus dorsi musculocutaneous flap are planned. This patient will most likely show deficits in which of the following shoulder functions? (A)Extension and abduction (B)Extension and adduction (C)Flexion and abduction (D)Flexion and adduction (E)No deficits
(B)Extension and adduction
Functional deficits after latissimus doors musculocutaneous flap
Transfer of the latissimus dorsi musculocutaneous flap is associated withdeficits in extension and adduction.