Breast Reconstruction Flashcards
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 Staphylococcus species, 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.
2018
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.
2018
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.
2018
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.
2018
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.
2018
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.
2018
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.
2018
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.
2018
A 35-year-old woman with a Stage T2 infiltrating ductal carcinoma is scheduled to undergo a skin-sparing, right total mastectomy and a nipple-sparing, left prophylactic mastectomy. The possibility of adjuvant radiation therapy to the right breast depends on the final surgical pathology. The patient has a history of smoking. BMI is 28 kg/m2. She wears a brassiere with a D cup and would like the postoperative result to be of a similar size. Which of the following immediate bilateral reconstructive techniques is most appropriate for this patient?
A) Abdominal-based free flaps
B) Gluteal-based free flaps
C) Latissimus dorsi myocutaneous flaps and silicone implants
D) Silicone implants and acellular dermal matrix
E) Tissue expanders and acellular dermal matrix
The correct response is Option E.
For this patient in whom postoperative radiation therapy is possible, the best first-stage, immediate reconstructive approach is placement of tissue expanders with acellular dermal matrix. The outcome of immediate autologous flap reconstruction may be compromised if subjected to adjuvant radiation therapy and is best delayed until after such treatment has been rendered. Although successful, cost-effective outcomes are possible with a single-stage, direct-to-implant approach, this patient has risk factors for early revision and implant failure due to her large breasts and history of smoking.
2018
After a nipple-sparing mastectomy, which of the following branches of an intercostal nerve predominantly provides remaining sensation to the nipple-areola complex?
A) Anterior branch of the fifth
B) Anterior branch of the fourth
C) Lateral branch of the fifth
D) Lateral branch of the fourth
E) Lateral branch of the third
The correct response is Option B.
The cutaneous innervation of the female breast is derived medially from the anterior cutaneous branches of the first to sixth intercostal nerves and laterally from the lateral cutaneous branches of the second to seventh intercostal nerves. The nipple-areola complex is physiologically innervated by the lateral and anterior branches of the third to fifth intercostal nerves. The fourth intercostal nerve has further shown to be most consistent in various anatomical studies.
However, the anterior branches take a superficial course within the subcutaneous tissues of the medial breast while the lateral branches take a deep course within the pectoral fascia and reach the nipple via the breast parenchyma. Therefore, the lateral branches are most likely resected during mastectomy and contribute little to the postoperative innervation of the nipple-areola complex.
2018
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.
2018
A 46-year-old woman with cancer of the right breast comes to the office to discuss a right mastectomy with immediate implant reconstruction and a symmetry procedure for the contralateral breast. Physical examination shows bilateral Grade 3 ptosis with volume symmetry. The patient currently wears a size 34C brassiere and desires to remain the same size. Which of the following is the most appropriate procedure for the contralateral breast?
A) Augmentation mammaplasty
B) Fat injections
C) Mastopexy
D) Reduction mammaplasty
The correct response is Option C.
Contralateral breast procedures are frequently necessary to achieve symmetry following mastectomy and reconstruction. Options to achieve symmetry include mastopexy, reduction mammaplasty, or augmentation mammaplasty combined with mastopexy. Volume symmetry can be achieved through reduction mammaplasty or fat injections. Positional asymmetry of the contralateral breast and the nipple-areola complex may require correction with mastopexy. Augmentation mammaplasty with mastopexy may be indicated for the correction of volume and positional asymmetry. The most appropriate contralateral procedure in a patient with symmetric volumes of the breast and ptosis of the contralateral breast is mastopexy.
2018
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.
2018
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.
2018
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.
2018
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.
2018
Following a skin-sparing mastectomy, a 39-year-old woman undergoes deep inferior epigastric perforator (DIEP) flap breast reconstruction. To augment flap sensation, the anterior sensory branch of the fourth intercostal nerve is coapted to which of the following nerves within the DIEP flap?
A) Genitofemoral
B) Iliohypogastric
C) Ilioinguinal
D) Intercostal
E) Lateral femoral cutaneous
The correct response is Option D.
The third, fourth, and fifth intercostal nerves are responsible for innervation of the majority of the breast. The anterior branch of the fourth intercostal nerve provides most erogenous sensation to the nipple. Sensation to the lower abdomen arises from segmental cutaneous branches of the intercostal nerve, which travel through the rectus abdominis muscle. T10 provides sensation to the dermatome, including the periumbilical region, and is most commonly used. The iliohypogastric nerve provides sensation to the lateral gluteal region. The ilioinguinal nerve provides sensation to the upper medial thigh. The genitofemoral nerve provides sensation to the upper anterior thigh and mons pubis. The lateral femoral cutaneous nerve provides innervation to the lateral thigh and is not used for this purpose.
2017
Which of the following is a risk factor for hormone-sensitive breast cancer?
A) Breast-feeding
B) Early age at first pregnancy
C) Early menopause
D) Late menarche
E) Post-menopausal obesity
The correct response is Option E.
Post-menopausal obesity is associated with increased adipose production of estrogen, which can increase the risk for hormone-sensitive breast cancer. Other options (late menarche, early menopause, and breast feeding) decrease the number of menstrual cycles, and therefore may decrease the risk of breast cancer. Early age at first pregnancy is also associated with decreased risk for hormone-sensitive breast cancers.
2017
A 54-year-old woman with BRCA mutation is scheduled for a bilateral nipple-sparing mastectomy. Which of the following would lead to the highest risk for postoperative nipple necrosis?
A) Grade 2 breast ptosis
B) Periareolar mastectomy incision
C) Previous excisional breast scar
D) Tumor greater than 1.5 cm
E) Use of smooth round gel implants
The correct response is Option B.
Nipple-sparing mastectomy and direct to implant reconstruction is becoming increasingly popular in the setting of prophylactic mastectomies. The criteria for nipple-sparing mastectomies have been increased to tumors not involving the nipple-areola complex, with some surgeons requiring a distance of 2 cm from the nipple and others espousing just a clean surgical margin at the nipple. Nipple-sparing mastectomies do not require recreating the breast envelope and therefore direct to implant reconstruction is possible. Increased risk for incidence of nipple necrosis in the setting of direct to implant reconstruction is associated with mastectomy incision involving the areola. The use of smooth round gel implants, grade 2 ptosis, tumor size, or previous breast biopsy scars are not associated with nipple necrosis.
2017
An otherwise healthy 16-year-old girl comes to the office because of a painless mass in the left breast. Physical examination of the left breast discloses a circumscribed firm, rubbery, 3-cm mass without overlying skin changes, and no axillary lymphadenopathy. Results of a pregnancy test are negative. Which of the following is the most likely diagnosis?
A) Common fibroadenoma
B) Giant fibroadenoma
C) Lactating adenoma
D) Phyllodes tumor
E) Tubular adenoma
The correct response is Option A.
A common fibroadenoma is the most likely diagnosis of this patient. Common fibroadenoma is the most common breast tumor in adolescent females and present between the ages of 14 and 16.
Juvenile fibroadenoma is a variant of fibroadenoma and is usually seen in adolescents and young adults. It is associated with a normal stromal/epithelial balance, which distinguishes it from phyllodes tumor, and has both stromal and epithelial hyperplasia. In addition, juvenile fibroadenomas are characterized by rapid growth.
A giant fibroadenoma is a clinical diagnosis, rather than a pathologic diagnosis. It is characterized by its size, usually greater than 5 cm.
Complex fibroadenoma is characterized by fibrocystic changes on glandular tissue with underlying features of common fibroadenoma on pathologic analysis.
A tubular adenoma has glandular proliferation on pathologic analysis, and while it is a subtype of fibroadenoma, it is not as common as common fibroadenoma. A lactating adenoma, similarly, is defined by the presence of secretory hyperplasia of lobules on pathologic analysis. Lactating adenomas are so defined because of the histologic presence of secretory hyperplasia, and they commonly occur in pregnant or lactating women. Many lactating adenomas will spontaneously regress.
A phyllodes tumor is typically a large, rapidly growing lesion and can be either benign or malignant. It is rare in adolescents, but when found, is usually aggressive. Phyllodes tumor is related to fibroadenoma and is distinct from other forms of breast cancer. Treatment is wide local excision.
2017
A 30-year-old woman comes to the office because of pain in the left breast. Two weeks ago, she underwent core needle biopsy of a breast mass that was diagnosed as benign. Family history does not include breast cancer. She does not smoke cigarettes. On examination, the left breast is erythematous and tender to palpation, and the skin of the breast is retracted laterally. There is a palpable, rope-like mass that courses longitudinally along the breast. Which of the following is the most appropriate diagnosis and treatment of this lesion?
A) Breast abscess, perform incision and drainage of the mass
B) Fibrocystic changes, perform biopsy
C) Mastodynia, treat with 10-day course of broad-spectrum antibiotics
D) Nipple papilloma, perform diagnostic mammography
E) Superficial thrombophlebitis, manage with analgesics
The correct response is Option E.
Mondor disease, or superficial thrombophlebitis of the breast, involves the superficial veins of the breast and anterior chest wall. It may occur following surgery, core biopsy, irradiation, or trauma. Clinical manifestations include pain, redness and swelling, and the presence of a thickened tender cord. This condition usually resolves in 4 to 6 weeks with symptomatic treatment using pain relief.
Nipple papillomas may be identified as a mass on breast imaging or may be found incidentally. They frequently present with bloody nipple discharge. While not concerning in and of themselves, these lesions may harbor areas of atypia or ductal carcinoma in situ, and are treated with core needle biopsy.
While a breast abscess is possible after a diagnostic procedure such as a biopsy, it would present as localized swelling, tenderness, and induration. The skin retraction and rope-like mass would not be present.
Fibrocystic changes in the breast present as a solitary mass and may cause patients to seek medical attention because of associated pain. They may fluctuate in size and tenderness during a patient’s menstrual cycle. Because no breast mass can be definitively declared benign on physical examination alone, imaging and/or biopsy may be considered.
Breast pain in the absence of a finding on physical examination may have a number of causes including menstrual changes, breast hypertrophy, diet, hormone replacement therapy, ductal ectasia, mastitis, malignancy, and hidradenitis. While the patient does have breast pain, the other physical findings rule out mastodynia alone.
2017
Oral contraceptive use increases the incidence of which of the following histologic risk factors for breast cancer?
A) Apocrine metaplasia
B) Atypical hyperplasia
C) Intraductal hyperplasia
D) Intraductal papilloma
E) Sclerosing adenosis
The correct response is Option B.
Patients in whom an otherwise benign breast biopsy shows atypical hyperplasia have a 4.5- to 5-fold increased risk for developing breast cancer. Proliferative breast disease without atypia increases the risk 1.5- to 2-fold. Oral contraceptives have shown to decrease the occurrence of all proliferative forms of benign breast disease without atypia, such as intraductal hyperplasia, intraductal papilloma, and sclerosing adenosis. Apocrine metaplasia is a non-proliferative histologic change and carries no increased risk for breast cancer. Of the choices, only atypical hyperplasia is increased with oral contraceptive use.
2017
A 42-year-old nurse is scheduled to undergo elective non–implant-based surgery of the left breast. Medical history includes no abnormalities, and she has no allergies. She smokes 1 pack of cigarettes daily. To decrease the incidence of surgical site infection, which of the following is the most effective perioperative strategy?
A) Administer cefazolin intravenously within 5 minutes of skin incision
B) Administer an insulin drip to keep blood glucose concentration less than 100 mg/dL
C) Have the patient practice complete smoking cessation for 7 days prior to surgery
D) Prescribe nasal mupirocin and chlorhexidine baths for 5 days prior to surgery
E) Use povidone-iodine skin preparation rather than chlorhexidine/isopropyl alcohol
The correct response is Option D.
A 2010 randomized controlled trial of over 6700 patients published in the New England Journal of Medicine documented a nearly 60% decrease in Staphylococcus aureus infections in patients if mupirocin was applied twice a day to the nares as well as a full-body wash with chlorhexidine for 5 days prior to surgery. The mean hospital stay was already reduced almost 2 days. A meta-analysis also demonstrated the same findings, with a nearly 45% decrease in surgical site infections (SSIs).
Data would suggest that isopropyl alcohol–containing skin preparations for surgery decrease SSI rates more effectively than povidone-iodine alone.
Perioperative antibiotics should be administered with enough advance time to achieve proper and adequate rates of skin penetration. With cefazolin, this is 30 to 59 minutes before skin incision, with an odds ratio of 1.0 (vs. 2.0 if given within 30 minutes, and 1.7 if given after 60 minutes). Five minutes prior to skin incision is not sufficient for the SSI-reducing effect to be achieved.
Blood glucose control is critical to decreasing SSI rates, with optimal rates usually being quoted as less than 180 mg/dL. However, this patient is not diabetic; she is otherwise healthy, so an insulin drip would not be appropriate. In addition, hypoglycemia can also have detrimental physiologic effects and also should be avoided.
Smoking cessation decreases SSI rates if the patient does not smoke for 4 weeks before or after surgery. A 2012 systematic review and meta-analysis of nearly 500,000 patients demonstrated this. However, 7 days of smoking cessation is insufficient time in advance of surgery to obtain these statistically significant benefits.
2017
A 45-year-old woman comes to the office for consultation regarding severe breast asymmetry after undergoing lumpectomy and radiation therapy for ductal carcinoma of the right breast 5 years ago. Physical examination shows the radiated right breast is tight and retracted, and the left breast is ptotic. Left-sided mastopexy for symmetry and autologous fat grafting to the radiated breast are recommended. The patient asks if the procedure will be covered by insurance. Which of the following is the most appropriate response?
A) Fat grafting the right breast will be covered by insurance but the mastopexy will be considered cosmetic and will not be covered
B) Insurance companies rarely cover the cost of immediate breast reconstruction
C) Insurance may not cover the procedure since insurers are not mandated to pay for reconstruction of lumpectomy defects
D) Procedures for both sides will be covered by insurance
E) The left-sided mastopexy will likely be covered but the fat grafting will not be covered
The correct response is Option C.
The Women’s Health and Cancer Rights Act, signed into law in 1998, requires insurance plans to cover the cost of breast reconstruction after mastectomy. The law includes all stages of reconstruction as well as contralateral procedures to provide symmetry. An often misunderstood aspect of the Women’s Health and Cancer Rights Act is that it does not apply to individuals undergoing breast conservation therapy (lumpectomy with radiation). As rates of breast conservation therapy have continued to increase (60% of women with stage I cancers), so have significant lumpectomy defects associated with the untoward effects of radiation. In the clinical scenario presented, the patient should be informed that the corrective operation (fat grafting and mastopexy) might not be covered by her insurance company.
2017
A 35-year-old woman comes to the office to discuss a recent diagnosis of breast cancer. Recent mammography showed diffuse microcalcifications throughout the breast, and needle biopsy showed infiltrating ductal carcinoma. On physical examination, some retraction of the skin in the lower outer quadrant of the breast is noted. She wears a size 36C brassiere. The patient reports that she is currently considering whether to have lumpectomy and radiation therapy or mastectomy. Which of the following features of this clinical scenario is a CONTRAINDICATION to breast conservation therapy?
A) Breast size
B) Mammographic findings
C) Patient age
D) Skin retraction on physical examination of the breast
E) Tumor pathology
The correct response is Option B.
Breast conservation therapy (BCT) refers to breast conserving therapy followed by moderate-dose radiation to eradicate microscopic residual disease. The goal is to provide the equivalent survival of mastectomy while maintaining a cosmetically acceptable appearance with a low rate of recurrence.
When considering breast conservation therapy or mastectomy, the needs and desires of each patient should be addressed. Age alone is not a contraindication to BCT, but overall health and comorbidities should be considered. Histologic subtype and pathology are not contraindications to BCT as long as the tumor is not diffuse and can be safely excised with negative margins. Similarly, breast size needs to be considered along with tumor size and location, but “small” or “large” breasts are not indications or contraindications. While retraction of the skin, nipple, or breast parenchyma is not an absolute contraindication to BCT, as long as negative margins can be safely removed, the cosmetic impact of their involvement should be considered.
There are few absolute contraindications to BCT, but they include:
Multicentric disease with two or more tumors in separate quadrants of the breast such that they cannot be encompassed in a single excision
Diffuse malignant microcalcifications on mammography
A history of prior radiation in the same breast or chest wall
Pregnancy
Persistently positive margins despite re-excision
2017
A 52-year-old woman undergoes immediate unilateral breast reconstruction with a free deep inferior epigastric flap. Near completion of the procedure, the flap skin paddle is noted to have venous congestion. On exploration of the pedicle, the anastomosis between the vena comitans and the internal mammary vessel appears patent. Which of the following preventive measures would most likely have averted this issue?
A) Administration of heparin immediately before release of vessel clamps and flap revascularization
B) Anastomosis of the veins using sutures instead of a venous coupling device
C) Preservation and anastomosis of the superficial inferior epigastric vein
D) Routine anastomosis of two venae comitantes per flap
E) Use of near-infrared fluorescence imaging to assess flap blood flow
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 interrogated. Simple issues, such as mechanical compression or twisting of the vein should be ruled out. Next, the SIEV should be inspected. If it is engorged, it is likely that the flap is 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.
Near-infrared fluorescence imaging technology can assist with flap design and may be useful for assessing the arterial inflow of the flap, but it has not been shown to correlate with flap loss or venous complications.
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 decrease the velocity of blood flow across the anatomosis, there are no data to support differences in flap outcomes or thrombotic events. Therefore, the routine use of a second vein is largely up to surgeon preference.
Heparin may be a useful adjunct when thrombosis of the arterial or venous anastomosis is excised and a revision of the anastomosis is performed. Without evidence of thrombosis, it is unlikely to have any added benefit.
For venous anastomoses, the use of venous coupling devices has not been associated with patency issues or increased thrombosis rates. Therefore, a hand-sewn anastomosis is not likely to prevent the issue presented in this question.
2016
A 36-year-old woman with genetic susceptibility to breast cancer is scheduled to undergo bilateral prophylactic mastectomy. She has elected to proceed with immediate single-stage reconstruction using permanent silicone implants and acellular dermal matrix. Which of the following is the most sensitive method to detect implant rupture in this patient?
A) CT scan
B) Mammography
C) MRI
D) Physical examination
E) Ultrasonography
The correct response is Option C.
Implant rupture is one of the most common reasons for implant removal. While implant rupture can be associated with symptoms such as capsular contracture, it is often completely asymptomatic or “silent.” For this reason, screening imaging to detect such ruptures has been recommended.
According to the 2011 Update on the Safety of Silicone Gel-Filled Breast Implants published by the U.S. Food and Drug Administration, it is currently recommended that women with silicone implants get their first MRI 3 years after they receive the implants and every 2 years thereafter to detect silent ruptures.
Since the rate of rupture increases the longer an implant is in place, not screening is unacceptable.
Mammograms can detect extracapsular silicone when an implant ruptures, but they do not detect intracapsular ruptures.
The accuracy of ultrasound largely depends on the skill of the ultrasound technologist, the type of equipment used, and the experience of the interpreting physician. Furthermore, ultrasound is limited in its ability to detect ruptures in the back wall of the implant and in the breast tissue behind it.
CT scans can detect intracapsular silicone gel-filled breast implant rupture, but they are limited in their ability to detect extracapsular ruptures.
2016
A 53-year-old woman comes to discuss breast reconstruction after undergoing left mastectomy for ductal carcinoma in situ. She does not require chemotherapy or radiation therapy and does not want surgery on the unaffected breast. She is obese but otherwise healthy with a large, ptotic right breast. Which of the following breast reconstruction techniques is most likely to result in the greatest long-term patient satisfaction?
A) Autologous breast reconstruction with microvascular free tissue transfer from the abdomen
B) Extended latissimus dorsi musculocutaneous flap reconstruction without an implant
C) Immediate reconstruction with cohesive, anatomically shaped silicone gel implant
D) Immediate tissue expander followed by implant-based reconstruction
E) Latissimus dorsi musculocutaneous flap reconstruction with immediate placement of a permanent implant
The correct response is Option A.
Multiple studies have supported improved patient satisfaction with autologous breast reconstruction in the setting of a unilateral reconstruction. The clinical scenario involves an obese patient with a large, ptotic breast who does not desire a surgical procedure for symmetry and is the ideal candidate for an autologous reconstruction. Microvascular free tissue transfer of abdominal tissue for breast reconstruction demonstrates improved reliability and decreased fat necrosis compared with pedicled flap reconstruction. Implant-based reconstruction is less likely to provide adequate symmetry in this patient. An extended latissimus dorsi musculocutaneous flap–based reconstruction alone is unlikely to provide enough volume for symmetry and a traditional latissimus flap with implant is unlikely to provide adequate ptosis for symmetry.
2016
A 43-year-old woman would like to discuss plans for breast reconstruction after her upcoming unilateral mastectomy. Postoperative radiation therapy is planned. Which of the following is the most likely benefit of tissue expander–based breast reconstruction compared with immediate autologous breast reconstruction using this patient’s abdominal tissue?
A) Better symmetry
B) Improved postoperative sensation
C) A larger, more ptotic breast reconstruction
D) Lower risk of complications from radiation
E) Preservation of the patient’s options for final reconstruction
The correct response is Option E.
Immediate breast reconstruction with tissue expanders followed by reconstruction of choice preserves the patient’s skin envelope and keeps open options for definitive final reconstruction of choice whether with an implant or autologous tissue.
Tissue expander-based reconstruction is associated with a higher complication rate in the setting of radiation therapy but preserves abdominal and back tissue as options for autologous reconstruction. Implant-based reconstruction does not provide the advantages of improved symmetry, sensation, or breast ptosis.
2016
A 62-year-old woman undergoes breast reconstruction using autologous tissue from the abdomen. Intraoperatively, use of a perforator flap is found to be impossible because of multiple small nondominant perforators. Conversion to a delayed pedicled transverse rectus abdominis muscle flap is planned. Ligating which of the following vessels in this stage will best facilitate future viability of the tissue transferred in the next stage?
A) Deep inferior epigastric
B) Hypogastric
C) Internal mammary
D) Superficial inferior epigastric
E) Superior epigastric
The correct response is Option A.
Pedicled transverse rectus abdominis muscle (TRAM) flaps are based on the superior epigastric system, which is often less robust than the deep inferior epigastric system. Therefore, surgical delay by ligation of the deep inferior epigastric system may facilitate overall viability of the transferred tissue. Ligation of the superior epigastric system would make a pedicled TRAM flap unlikely to survive. The internal mammary ligation may also interrupt blood supply to the superior epigastric system, and even if the tissue is fed through collaterals, it would not strengthen the flap. Division of the superficial inferior epigastric system might also help, but it is not as critical as ligation of the deep inferior epigastric system. The hypogastric system does not have a direct impact on the pedicled TRAM tissues.
2016
A 35-year-old BRCA-positive woman undergoes bilateral prophylactic nipple-sparing mastectomy via lateral radial incisions with periareolar extensions. She undergoes direct-to-implant reconstruction with an acellular dermal matrix inferior lateral sling. Mastectomy specimens weigh 435 g each, and placement of 450 mL smooth, round, high-profile implants is performed. Postoperatively, 25% partial nipple areolar complex necrosis in both breasts is noted. Which of the following most likely contributed to the necrosis?
A) Bilateral surgery
B) Mastectomy incision
C) Use of acellular dermal matrix
D) Volume of the implants
E) Weight of the mastectomy specimen
The correct response is Option B.
Nipple-sparing mastectomies are becoming more prevalent with the rise of prophylactic mastectomies and increased comfort with performing it in presence of in situ and invasive carcinoma. While universal standards for patient selection do not exist, there is consensus that general recommendations include no inflammatory breast cancers, no pathologic nipple discharge, no Paget’s disease, and for many, a 2-cm distance from the tumor to the nipple. Nipple-sparing mastectomy incisions have been described as radial lateral, lateral inframammary fold, and peri-areolar. Because the entire skin envelope is preserved, direct-to-implant reconstruction is possible with inferolateral support from acellular dermal matrices or other scaffolds. Areolar involvement in mastectomy incisions is associated with increased rates of nipple necrosis. The weight of mastectomy specimen, volume of implants, use of acellular dermal matrices or laterality of surgery have not been shown to be associated with nipple necrosis.
2016
An otherwise healthy 38-year-old woman who is a smoker is considering implant-based breast reconstruction following mastectomy. She has been counseled about likely use of acellular dermal matrix when the intermediate tissue expander is placed and wants to further understand why the matrix will be used in her body. The patient should be advised that use of acellular dermal matrix is associated with a decreased risk for which of the following?
A) Cancer recurrence
B) Capsular contracture
C) Seroma
D) Skin flap necrosis
E) Smoking-related complications
The correct response is Option B.
Acellular dermal matrix (ADM) use has been increasing over time with tissue expander or implant-based breast reconstruction following mastectomies. Many potential advantages and disadvantages have been studied, and some of the data are contradictory. However, the consensus of the literature indicates that ADMs are associated with decreased capsular contracture rates. There is literature to suggest that seroma rates are increased or remain stable, not decreased, with ADMs. ADMs have not been shown to decrease independent patient risk factors for complications such as tobacco use or to decrease cancer recurrence rates. ADMs also do not appear to improve vascularity of the tissue overlying them when initially placed.
2016
A 45-year-old woman undergoes mastectomy. Which of the following anatomical landmarks denotes a limit of the breast and, therefore, a limit to the extent of the mastectomy?
A) Anterior border of latissimus dorsi muscle
B) Inferior origin of pectoralis major muscle
C) Lateral pectoralis minor muscle
D) Superficial fascia of the serratus anterior muscle
E) Supraclavicular lymph node basin
The correct response is Option A.
The borders of the breast and, therefore, the limits of the mastectomy are the sternum, clavicle, inframammary fold, and anterior border of the latissimus dorsi muscle. The other options are not designated as borders of the breast tissue.
2016
A 57-year-old woman with a history of modified left radical mastectomy followed by adjuvant chemotherapy and radiation therapy is evaluated six months after her last radiation treatment for breast reconstruction. Physical examination shows slight skin redundancy of the chest wall and grade 2 ptosis of the contralateral breast. She wears a size 36D brassiere and does not want to undergo symmetry procedures on the contralateral breast. Which of the following reconstructive options is most likely to achieve breast symmetry in this patient?
A) Deep inferior epigastric perforator flap
B) Latissimus dorsi flap
C) Thoracodorsal artery perforator flap
D) Tissue expander with acellular dermal matrix and staged implant placement
E) Total submuscular tissue expander and staged implant placement
The correct response is Option A.
Breast reconstruction requires reconstruction of both the soft-tissue envelope and volume. In the setting of radiated chest wall tissues, it would be difficult to recreate a breast envelope of sufficient size to match the contralateral breast with tissue expansion, even with acellular dermal matrix or total submuscular placement of a tissue expander. The history of radiation would likely cause an element of capsular contracture and decrease symmetry to the contralateral breast with grade 2 ptosis. Both the latissimus dorsi flap and the thoracodorsal artery perforator flap would recruit non-radiated skin to create an adequate envelope, but would not provide adequate volume alone. The deep inferior epigastric perforator (DIEP) flap would provide both envelope and volume.
2016
A 53-year-old woman with a BMI of 27 kg/m2, gigantomastia, and grade III ptosis is considering unilateral mastectomy and autologous reconstruction with abdominal tissue. Which of the following is the most appropriate advice regarding the contralateral breast?
A) A contralateral prophylactic mastectomy should be performed to maximize symmetry
B) Contralateral reduction should be accompanied by placement of an implant on that side to address upper pole symmetry with the autologous reconstruction
C) Simultaneous contralateral reduction may be performed with an acceptable risk profile
D) Symmetry is unlikely to be achieved, so a contralateral matching procedure would not be recommended
E) Symmetry with autologous tissue is likely to be achieved without the contralateral matching procedure
The correct response is Option C.
Studies have shown that contralateral symmetry procedures performed synchronously with unilateral autologous tissue reconstruction after mastectomy (including reconstructions with a free perforator flap) are acceptable. Situations requiring reduction rather than augmentation or mastopexy seem to be the most suited to this timing. A patient with a lower BMI and gigantomastia is unlikely to achieve symmetry without a contralateral procedure. Autologous tissue reconstruction likely would not need a contralateral implant for upper pole symmetry. An attempt at improvement in symmetry using contralateral surgery would be acceptable should the patient so choose, but recommending a prophylactic mastectomy on the contralateral side solely for symmetry and not for risk reduction may be overly aggressive when other methods such as reduction mammaplasty exist with a likelihood of acceptable postoperative symmetry.
2016
Which of the following is the most accurate location of the elliptical skin island of a profunda artery perforator (PAP) flap?
A) Anteromedial thigh with the superior border within the groin crease
B) Inferior buttock with the inferior border within the gluteal fold
C) Lateral hip superior to the iliac crest
D) Middle buttock, from the posterior superior iliac spine to the apex of the greater trochanter
E) Posteromedial thigh with the superior border within the gluteal fold
The correct response is Option E.
According to the literature, the skin island of the profunda artery perforator (PAP) flap is inferior to the gluteal fold.1,2 An ellipse of the inferior buttock with the inferior border within the gluteal fold describes the skin island of the inferior gluteal artery perforator (IGAP) free flap.3 An ellipse of the anteromedial thigh with the superior border within the gluteal fold describes the transverse upper gracilis (TUG) flap. An ellipse of the middle buttock, from the posterior superior iliac spine to the apex of the greater trochanter, describes the superior gluteal artery perforator (SGAP) flap.3 An ellipse of the lateral hip superior to the iliac crest describes the Rubens or lateral hip flap.4 The only option that correctly identifies the skin island for the PAP flap is an ellipse of the posteromedial thigh with the superior border within the gluteal fold. The superior marking is within or just below the gluteal fold and the inferior marking is roughly 7 cm below the superior marking. The flap is an ellipse so the scar does not extend outside of the gluteal fold.1,2
2016
Nipple-sparing mastectomy is CONTRAINDICATED in which of the following women considering mastectomy and immediate breast reconstruction?
A) A 21-year-old with BRCA1 mutation and grade I breast ptosis
B) A 31-year-old with BRCA2 mutation; subglandular augmentation mammaplasty 1 year ago
C) A 45-year-old with unilateral breast cancer and need for postoperative radiation therapy
D) A 50-year-old with unilateral breast cancer in the tail of Spence
E) A 61-year-old with unilateral breast cancer; tumor-to-nipple distance of 1 cm
The correct response is Option E.
Nipple-sparing mastectomy is increasingly prevalent owing to perceived improvement in reconstructive outcome and patient satisfaction. Prevalence of nipple ischemia, which can vary in severity from incomplete, partial-thickness epidermolysis to total nipple loss, ranges from 2 to 60% depending on the definition used. A recent pooled analysis found a cumulative prevalence of 7%. Most cases respond to local wound care; reoperation for total nipple loss is relatively infrequent.
Patient selection remains paramount to successful nipple preservation. Typically, thin, non-smoking patients with small, non-ptotic breasts are considered ideal candidates. Severe macromastia and ptosis may not only increase risk of poor nipple vascularity, but also contribute to nipple malposition. Oncologic determinants of the safety of nipple preservation should also be considered. Noninflammatory cancers located in excess of 2 cm from the nipple can generally be safely extirpated without removal of the nipple. Usually, an intraoperative frozen section biopsy of the retroareolar tissue (“doughnut”) is performed after excision of the main mastectomy specimen to demonstrate nipple margins free of tumor. Patients undergoing prophylactic mastectomy in the setting of high genetic predisposition are also considered good candidates. Successful nipple preservation has also been described in patients with a history of reduction mammaplasty or mastopexy.
Successful nipple-sparing mastectomy with implant reconstruction has been described recently in patients who require postoperative radiation, albeit with higher risk of capsular contracture and nipple malposition. Prior augmentation in the subglandular or subpectoral positions does not contraindicate nipple-sparing mastectomy; rather, the latter group may present opportunities for direct-to-implant reconstruction. Location of a breast cancer in the tail of Spence (axillary extension of breast tissue) should not contraindicate nipple-sparing mastectomy, as it is likely to be far enough from the nipple to safely spare it.
2016
A 62-year-old woman with a history of Stage III breast cancer is scheduled for delayed autologous breast reconstruction from the abdominal donor site. She has no other medical problems. BMI is 30 kg/m2. Her mother had a lower extremity deep venous thrombosis in the past. Caprini risk assessment score is 9. Which of the following is the most appropriate method of postoperative VTE risk reduction?
A) Aspirin therapy
B) Early ambulation after surgery
C) Low-molecular-weight heparin therapy
D) Sequential compression device use
E) No VTE prevention is indicated
The correct response is Option C.
Venous thromboembolism (VTE) is a disorder with short-term mortality and long-term morbidity. Plastic and reconstructive surgery patients are known to be at high risk for VTE after surgery. Symptomatic VTE occurs with high frequency after post-bariatric body contouring (7.7%), abdominoplasty (5%), and breast or upper body contouring (2.9%). To fully identify VTE risk in surgical patients, individualized patient assessment is advocated. The Caprini risk assessment model (RAM) is a useful and effective tool to stratify surgical patients for VTE risk. For patients with high Caprini scores, a significantly greater likelihood of VTE events is observed. Approximately 11% of patients with Caprini score >8 will have a VTE within 60 days after surgery.
Based upon recommendations from the ASPS VTE Task Force, patients undergoing elective plastic and reconstructive surgical procedures who have Caprini RAM score of 7 or more should have VTE risk reduction strategies employed, such as limiting operating room times, weight reduction, discontinuation of hormone replacement therapy, and early postoperative mobilization. Patients undergoing major plastic and reconstructive operative procedures performed during general anesthesia that last longer than 60 minutes should receive VTE prevention. For patients with Caprini score of 3 to 6, the use of postoperative low-molecular-weight heparin (LMWH) or unfractionated heparin (UH) should be considered. For patients with Caprini score of 3 or more, use of mechanical prophylaxis throughout the duration of chemical prophylaxis for non-ambulatory patients should be considered. For patients with Caprini score of 7 or more, the use of extended LMWH postoperative prophylaxis should be strongly considered.
Aspirin does not decrease the risk of VTE and may increase the risk of perioperative complications.
2015
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.
2015
A 42-year-old woman comes to the office for treatment after receiving a diagnosis of cancer of the right breast. She has decided to undergo mastectomy of the right breast. Which of the following is a relative CONTRAINDICATION to nipple-sparing mastectomy?
A) Comedo-type breast tumor
B) Invasive lobular carcinoma
C) Subareolar tumor
D) Tumor location 3 cm from the nipple
E) Tumor size of 2.5 cm
The correct response is Option C.
A relative contraindication to nipple-sparing mastectomy is a centrally located tumor. Although various authors have employed different distance criteria, it is generally accepted that patients whose tumors are within 2 cm of the nipple are not candidates for nipple-sparing mastectomy.
Nipple-sparing mastectomy is an appropriate option for high-risk patients undergoing prophylactic mastectomy and for patients diagnosed with breast cancer who meet certain criteria. Those criteria are: tumor size of 3 cm or less, at least 2 cm from the nipple, not multicentric, and with clinically negative nodes.
Comedo carcinoma of the breast is a type of ductal carcinoma in situ. It is considered to be an early stage of breast cancer, is confined to the ducts, and usually does not spread beyond. It is not a contraindication to nipple-sparing mastectomy.
Invasive lobular carcinoma originates from the breast lobules, may form a thickening of the breast tissue rather than a discrete mass, and is often bilateral. As long as it meets the above criteria, it is not a contraindication to nipple-sparing mastectomy.
Inflammatory breast cancer, Paget disease, and tumors infiltrating the skin are also not candidates for skin-sparing or nipple-sparing mastectomy, according to several authors.
In more recent studies, a tumor size of 3 cm or less appears to result in no increase in local or regional recurrence in nipple-sparing mastectomy compared with alternative surgical approaches. A tumor of 2.5 cm is not a contraindication to nipple-sparing mastectomy.
2015
Which of the following characteristics is correlated with increased risk of nipple-areola complex necrosis in nipple-sparing mastectomies with immediate reconstruction?
A) Autologous tissue reconstruction
B) Direct to implant reconstruction
C) Patient age
D) Periareolar incision
E) Small breast size
The correct response is Option D.
Nipple-sparing mastectomies (NSMs) are becoming more common for both therapeutic and prophylactic mastectomies. Nipple-areola complex (NAC) necrosis can imperil reconstructive efforts, as well as negatively affect patients emotionally. It is important to maximize perfusion to the mastectomy skin flaps and NAC while still performing an oncologically sound procedure. There are multiple different incisions for performing NSM. Periareolar, inframammary-fold, radial, and vertical incisions are the most common. Periareolar incisions are associated with an increased risk of NAC necrosis in NSMs. Type of reconstruction, small breast size, and patient age have not been shown to be linked to increased rates of NAC necrosis.
2015
A 52-year-old woman receives a diagnosis of invasive ductal carcinoma of the right breast. Which of the following details from this patient’s history is the strongest risk factor for this diagnosis?
A) Early first pregnancy (less than 30 years)
B) Early menarche (less than 12 years)
C) Early menopause (less than 55 years)
D) Multiple episodes of breast-feeding
E) Remote oral contraceptive use
The correct response is Option B.
Early menarche is the highest risk factor for breast cancer of the options listed. Late first pregnancy, late menopause, no breast-feeding, and recent oral contraceptive use are also risk factors for breast cancer but are not as high risk.
A 42-year-old woman with a 3-cm invasive ductal carcinoma of the right breast is evaluated for breast reconstruction. She has not decided how she wants to manage her contralateral breast. Regarding eliciting a family history, which of the following cancers is associated with a mutation in a breast cancer-susceptibility gene?
A) Colon
B) Esophageal
C) Lung
D) Pancreatic
E) Thyroid
The correct response is Option D.
The breast cancer-susceptibility gene types 1 and 2 (BRCA1 and BRCA2) are tumor suppressor genes. Mutations in BRCA1 and BRCA2 are associated with hereditary breast and ovarian cancers. Additionally, they can be associated with increased risks of pancreatic and prostate cancer. Thyroid, lung, esophageal, and colon cancer are not associated with increased risks of BRCA1 and BRCA2 mutations.
2015
A 35-year-old woman comes to the office for consultation regarding prophylactic mastectomy and breast reconstruction. The patient’s mother and sister were diagnosed with bilateral breast cancer in their premenopausal years. Genetic testing for BRCA mutations is negative. Which of the following best estimates this patient’s lifetime risk of breast cancer?
A) 5%
B) 13%
C) 20%
D) 45%
E) 80%
The correct response is Option D.
The cumulative lifetime risk for a 35-year-old woman whose mother and sister had breast cancer is estimated to be approximately 15%. The risk may increase to as high as 45% if those cancers were premenopausal and bilateral. BRCA hereditary cancer is characterized by autosomal dominant genetics with multiple family members in each generation being affected. For patients with BRCA1 mutation, the risk of breast cancer has been estimated to be between 50 and 80% by age 65 years. The risk of developing ovarian cancer has been estimated to be 10% by age 60 years.
2015
A 39-year-old woman with a history of fibrocystic breast lesions comes to the office for consultation. She has no family history of breast cancer. Results of routine mammograms have been negative; she has never undergone biopsy. Which of the following is the most appropriate recommendation for this patient regarding managing her risk of breast cancer?
A) Continue to schedule routine mammograms
B) Refer for mastectomy
C) Schedule core needle biopsy
D) Schedule fine-needle aspiration
E) Schedule genetic testing
The correct response is Option A.
Studies have shown the fibrocystic changes alone in the breast are not directly linked to an increased risk of breast cancer, so there is no indication for fine-needle aspiration or core biopsy. Cancer risk increases in benign breast disease with increased proliferation and atypical hyperplasia. Even with no family history of breast cancer, it is recommended that the patient continue routine mammograms. Fibrocystic breast disease has not been linked in the literature to an increased risk of mutations of the BRCA genes; therefore, genetic testing is unnecessary.
2015
An otherwise healthy 37-year-old woman presents for delayed microsurgical breast reconstruction. Which of the following is associated with use of tamoxifen?
A) Hemodynamic instability
B) Impaired wound healing
C) Increased bleeding
D) Seroma formation
E) Thromboembolic events
The correct response is Option E.
Breast cancers that are estrogen receptor positive may be responsive to adjuvant chemotherapy with selective estrogen receptor modulators such as tamoxifen, which can reduce recurrence and mortality. Tamoxifen is associated with thromboembolic events, such as deep venous thrombosis and pulmonary embolism. This prothrombotic effect has been postulated to be secondary to the effect of tamoxifen on estrogen receptors that are abundant within vascular endothelium.
Tamoxifen has been shown to be associated with increased rates of total flap loss and decreased rates of flap salvage when taken within 28 days of microsurgical breast reconstruction, which represents two half-lives of the active metabolite of tamoxifen (N-desmethyl tamoxifen, t1/2=14 days). It has therefore been recommended that in patients undergoing microsurgical breast reconstruction, tamoxifen be held for at least 28 days preoperatively. Some authors have further advised holding the medication postoperatively in addition to preoperatively.
Tamoxifen is not associated with impaired wound healing, increased bleeding, hemodynamic instability, or seroma formation.
2014
An otherwise healthy 38-year-old woman undergoes prophylactic bilateral mastectomy and immediate reconstruction with deep inferior epigastric artery perforator (DIEP) free flaps. Intraoperatively, the left DIEP flap appears congested before the conclusion of the case. The left deep inferior epigastric artery and vein (DIEA and DIEV) were anastomosed to the proximal internal mammary vessels. The vascular pedicle is evaluated and each anastomosis appears patent and not kinked; however, the venous congestion persists. Which of the following is the most appropriate management?
A) Anastomose the superficial inferior epigastric vein to an internal mammary vessel perforator
B) Convert to left prosthetic reconstruction
C) Infuse tissue plasminogen activator (tPA) to the DIEA
D) Initiate leech therapy
E) Revise the DIEV anastomosis to the retrograde internal mammary vessel limb
The correct response is Option A.
Venous drainage of the lower abdominal skin and subcutaneous tissue occurs primarily through the superficial venous system and secondarily through the deep venous system, with perforating veins interconnecting the two systems. These communicating veins have been identified on computed tomography angiography in approximately 90% of abdominal walls in vivo. The majority of the remaining 10% of patients likely have communicating veins that are too small to visualize or are absent. In these cases of anatomical superficial venous system dominance, venous drainage is dependent on the superficial venous system. A recently published 2012 article by Sbitany et al. demonstrated that the incidence of intraoperative venous congestion secondary to persistent superficial venous system dominance was 0.9% in 1201 muscle-sparing transverse rectus abdominis musculocutaneous and deep inferior epigastric artery perforator free flaps. A free flap that becomes congested after reperfusion in the operating room should be assessed immediately for possible etiologies including twisting, kinking, tension, or vasospasm of the vascular pedicle. If a technical problem is ruled out and the venous anastomosis remains patent, obligatory enhancement of venous drainage with the superficial venous system is necessary to salvage the free flap rather than revision of the original anastamosis. Various methods include an anastomosis of the superficial inferior epigastric vein (SIEV) to the DIEV system or any chest wall vein, including the retrograde limb of the internal mammary vessel, the branch of the internal mammary vessel, or the thoracodorsal system. This requires preemptive planning and sparing of the superficial epigastric vein or SIEV during the dissection of the flap. A vein graft can be utilized if additional length is necessary. Another option is to substitute the DIEV anastomosis with the SIEV.
Tissue plasminogen activator (tPA) would not be indicated in this scenario, as it is used as a thrombolytic and there is no evidence of vascular thrombosis. Revising the DIEV anastomosis would be moot because it is patent and the deep system is being drained. Leech therapy is useful for venous congestion, but primarily as an adjunct after potential surgical etiologies have been addressed. Sacrificing the free flap without first attempting salvage is not warranted, and using a prosthetic would be possible only if prior patient consent were obtained.
2014
A 60-year-old woman with breast cancer undergoes a transverse rectus abdominis musculocutaneous flap breast reconstruction after mastectomy. She has no allergies. Weight is 200 lb (91 kg). Estimated blood loss is 200 mL. Duration of the operation is 3 hours and 50 minutes. Administration of cefazolin before skin incision is planned as prophylaxis against surgical site infection. Which of the following is the most appropriate dosage and timing of this injection?
DoseTimingRedosing
A) 1g, 5 minutes prior, after 150 mL of blood loss
B) 1g, 15 minutes prior, no
C) 1g, 40 minutes prior, no
D) 2g, 15 minutes prior, no
E) 2g, 40 minutes prior, no
The correct response is Option E.
There has been a renewed interest in perioperative antibiotics in recent years toward more appropriate use to decrease surgical site infection (SSI) while decreasing the incidence of resistant bacteria.
Current recommendations are to administer a single perioperative dose of antibiotics against common skin flora (gram positive), usually using a first-generation cephalosporin. However, the following recommendations may be underappreciated:
Cefazolin intravenous:1 g if <80kg; 2g if >80kg
Alternatives:clindamycin 600 to 900mg intravenously;
vancomycin 1 to 1.5g intravenously
In this case, the patient weighs 200lb (91kg), so 2g of cefazolin is the recommended dosage.
Additionally, an important factor is the timing of the administration of the perioperative antibiotics in order to achieve proper skin levels before incision. In one study by Classen et al., published in the New England Journal of Medicine in 1992, the optimal time was between 2 hours before the operation and skin incision, as greater than 2 hours before and any time after skin incision led to marked increases in the relative risk of SSIs. A follow-up by Weber et al. in 2008 narrowed the most appropriate window to between 30 and 59 minutes before skin incision.
Finally, there is the issue of redosing. Current recommendations are to redose if there is excessive blood loss (>1500 mL) or if there are long procedures where one exceeds the half-life of the antibiotic used.
In the clinical scenario described, the most appropriate choice is 2 g of cefazolin, because the patient’s weight is above 80 kg, administered between 30 to 59 minutes before skin incision. Redosing on the basis of blood loss is unnecessary, although one could consider redosing at approximately 4 hours on the basis of half-life.
2014
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.
2019
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.
2019
A 52-year-old woman undergoes autologous breast reconstruction with unilateral deep inferior epigastric perforator (DIEP) flaps. According to the Hartrampf model of perfusion zones, if the lateral row perforator vessels are used, in which chronological order will the flap zones be perfused?
A) I – II – III – IV
B) I – III – II – IV
C) II – I – III – IV
D) II – I – IV – III
E) IV – III – II – I
The correct response is Option B.
In medial perforator-based flaps, the zones are perfused in the order I – II – III – IV (A) as shown in the image. In lateral perforator-based flaps, however, the zones are perfused in the order I – III – II – IV (B).
A 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.
2022
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.
2022
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.
2022
