Breast Reduction Flashcards
A 44-year-old woman, gravida 4, para 3, is evaluated because of symptomatic macromastia. Bilateral reduction mammaplasty is planned. The patient’s mother was diagnosed with postmenopausal breast cancer at 53 years of age; the patient underwent genetic testing which was negative for BRCA mutation. Physical examination shows the patient wears a size 32F brassiere and has grade III ptosis, shoulder grooving, dense breast tissue without palpable masses or nipple discharge, and intertrigo. According to current American Cancer Society recommendations, which of the following breast imaging methods should be used before the planned reduction mammaplasty in this patient?
A) Diagnostic mammography B) MRI C) Screening mammography D) Thermography E) Ultrasonography
The correct response is Option C.
The American Society of Plastic Surgeons participates in the Choosing Wisely campaign, which advocates for evidence-based guidelines in determining diagnostic and therapeutic interventions.
The American College of Surgeons’ recommendations for breast cancer screening in average-risk, asymptomatic women are for an opportunity for a baseline mammogram at 40 to 44 years of age, annual screening from 45 to 54 years of age, and biennial screening for women older than 55 years of age who are in good health and have a life expectancy of at least ten years.
This patient is asymptomatic, and is not a BRCA carrier, and meets criteria for a screening mammogram.
A diagnostic mammogram is performed to evaluate abnormalities found on screening mammogram, in the context of breast cancer history, or with physical exam findings such as a breast mass, nipple discharge, or breast pain.
MRI is recommended as an adjunct to mammography in the case of a known BRCA mutation, if the first-degree relative is known to have the BRCA mutation but the patient is untested, or if there is a lifetime risk of 20 to 25% of breast cancer.
Thermography uses an infrared camera to show patterns of blood flow and heat on the surface of the breast. It is not a replacement for mammography, not recommended as part of screening protocols, and is not associated currently with any quality studies that demonstrate that it can be used effectively as a screening tool for breast cancer.
Ultrasonography is also used as an adjunct to screening mammography.
It is important to note that different societies have different recommendations on timing of screening mammography. The ACS recommends screening at 45 years of age, the American College of Radiology recommends screening starting at 40 years of age, and the USPSTF recommends biennial mammograms between 50 and 74 years of age.
2018
In a Wise-pattern reduction mammaplasty using the superior medial pedicle, sensation is provided to the nipple-areola complex by which of the following nerves?
A) Lateral cutaneous branch of the fourth intercostal nerve
B) Lateral cutaneous branch of the second intercostal nerve
C) Medial pectoral nerve
D) Terminal branches of the fourth and fifth anterior intercostal nerves
E) Terminal branches of the second and third anterior intercostal nerves
The correct response is Option D.
The nipple-areola complex is innervated by the lateral cutaneous branch of the fourth intercostal nerve as well as the terminal branches of the fourth and fifth anterior intercostal nerves. However, when a superior medial pedicle in a reduction mammaplasty is used, the contribution from the lateral branch of the fourth intercostal nerve is excised. The lateral cutaneous branch of the second intercostal nerve is also known as the intercostobrachial nerve, which provides sensation to the medial and posterior upper arm. The medial pectoral nerve innervates portions of the pectoralis major and minor.
2018
A 43-year-old woman comes to the office for consultation for reduction mammaplasty. She wears a DDD brassiere and wants her brassiere size to be decreased to a C cup. Current medications include oral contraceptive pills. She does not smoke cigarettes. Height is 5 ft 5 in (167 cm) and weight is 145 lb (65.7 kg). BMI is 23.8 kg/m2. Physical examination shows the suprasternal notch to nipple distance is 29 cm and inframammary fold to nipple distance is 16 cm. Regardless of technique, which of the following factors is most likely to result in an increased risk for postoperative fat necrosis in this patient?
A) Massive weight loss B) Oral contraceptive use C) Patient age D) Suprasternal notch to nipple distance E) Tissue resection weight
The correct response is Option E.
Fat necrosis is one of the more common complications associated with reduction mammaplasty. Regardless of technique, the rates of fat necrosis have been reported in the 2 to 10% range. Fat necrosis presents as firm, soft-tissue masses that usually resolve spontaneously. It can be associated with redness and mild discomfort and may be confused with an infectious process. The literature is inconsistent with respect to detailed cause and effect or definitive correlations between fat necrosis and risk factors. However, some are generally agreed upon as significant and are mostly consistent in studies. Some of these risk factors for the development of fat necrosis include greater BMI, larger resection weights (both absolute and controlled for preoperative breast size), and long suprasternal notch to nipple distance (especially over 37 cm). Other factors that less clearly affect the rate of fat necrosis are smoking and the surgical technique employed.
Multiple studies have demonstrated increased risk of fat necrosis with greater obesity.
Although there have been some studies that suggest a correlation between fat necrosis and age, the studies have not reached a consensus nor have they shown statistical significance when evaluated in a controlled fashion. One study by Shermak et al. looked specifically at age-related risks and was not able to find a significant correlation with fat necrosis. There have been no studies or associations found to link exogenous hormone therapy or oral contraceptive use to increased fat necrosis. Alternatively, there has been some evidence to suggest that hormone supplementation might decrease the rate of infectious complications. The rate of fat necrosis and complication in general increases with longer suprasternal notch to nipple distances, most notably greater than 37 cm.
Massive weight loss is not associated with an increased risk for fat necrosis in the breast.
2018
Compared with reduction mammaplasty excisional techniques, which of the following is characteristic of liposuction-only reduction mammaplasty?
A) Does not typically impair breast-feeding potential
B) More effectively treats ptosis
C) Poses a higher risk to the blood supply of the nipple-areola complex
D) Results in a higher incidence of impaired sensation to the nipple-areola complex
E) Results in minimal swelling postoperatively
The correct response is Option A.
Liposuction-only reduction mammaplasty does not involve the use of a pedicle to ensure blood supply to the nipple. The nature of liposuction involves leaving major vessels and nerves intact and therefore does not pose an increased risk for blood supply loss to the nipple-areola complex. In addition, sensation to the breast as well as to the nipple-areola complex is not typically impaired following liposuction-only reduction mammaplasty. For similar reasons, breast-feeding potential is not typically compromised. The recovery from liposuction-only reduction mammaplasty can be quite significant, and it can take about 6 weeks for bruising and swelling to decrease and about 6 months for the breast to soften and for lumpiness to settle. Liposuction-only reduction mammaplasty does not work well when breast tissue is mostly glandular and thus has limited usefulness in those patients in whom it may seem most desirable, such as teenagers. Liposuction-only reduction mammaplasty does not more effectively treat ptosis.
2017
A healthy 42-year-old woman undergoes bilateral reduction mammaplasty for symptomatic breast hypertrophy. Pathologic analysis of one of the tissue specimens shows ductal carcinoma in situ. Which of the following percentages best represents the incidence of this finding in a reduction mammaplasty specimen?
A) 1% B) 7% C) 10% D) 12% E) 25%
The correct response is Option A.
The histologic finding is consistent with a diagnosis of ductal carcinoma in situ (DCIS). The incidence of occult breast cancer in reduction mammaplasty specimens most closely approximates 1%. Invasive ductal carcinoma is the most common malignant lesion identified, but DCIS, lobular carcinoma in situ, Paget disease, and fibrosarcoma have also been reported less frequently. All breast tissue removed from women older than 40 years should be sent to pathology for microscopic analysis.
2017
A 30-year-old woman with symptomatic macromastia is scheduled for a Wise pattern breast reduction. Which of the following postoperative complications is most likely in this patient?
A) Delayed wound healing B) Fat necrosis C) Hematoma D) Hypertrophic scarring E) Tear-drop deformity of the nipple-areola complex
The correct response is Option A.
In the 2005 prospective, multicenter trial of 179 patients by Cunningham, Gear, Kerrigan and Collins, reduction mammaplasty had an overall complication rate of 43%. The most common complication was delayed wound healing (21.6%), followed by spitting sutures (9.2%), hematoma (3.7%), nipple necrosis (3.6%), hypertrophic scars (2.5%), fat necrosis (1.8%), seroma (1.2%), and infection (1.2%).
Delayed wound healing correlated directly with average preoperative breast volume, average resection weight per breast, and smoking; and inversely with patient age. In this study, vertical techniques had a higher overall rate of complications.
In the Stevens, et al. report of their 11-year experience with outpatient breast reduction, delayed wound healing was also the most common complication.
2017
A healthy 27-year-old woman is evaluated 16 weeks after bilateral reduction mammaplasty with an inferior pedicle technique. Histologic examination of the resected tissue shows no malignancy. She reports a tender mass in the right breast that she noted 8 weeks after operation. She is now apprehensive because her mother had breast cancer at age 34. Physical examination of the affected breast shows a palpable, slightly tender, discrete, firm 2-cm subcutaneous mass beneath the upper areolar border. Examination shows no skin dimpling, nipple retraction, erythema, or edema. Which of the following is the most appropriate next step in management?
A) Conduct needle aspiration of the lesion
B) Inject triamcinolone acetonide suspension 20 mg into the mass
C) Proceed to surgery for removal of the mass
D) Refer the patient for an oncology consultation
E) Schedule ultrasonography and mammography of the affected breast
The correct response is Option E.
Postsurgical changes in the breast after reduction mammaplasty encompass a variety of physical and radiographic manifestations. On presentation of a breast mass after reduction mammaplasty, a diagnostic protocol is used to determine whether operative intervention is appropriate, to avert unnecessary biopsy and to avoid overlooking breast malignancy.
Fat necrosis, oil cysts, fibrosis, organizing hematoma, calcifications and, rarely, concurrent malignancy should be considered in this patient. In the absence of acute phenomena characteristic of a wound infection, work-up should consist of mammography and ultrasonography of the affected breast. Combining the radiographic findings with echographic appearance of the mass will help to differentiate fat necrosis and other benign conditions from the more ominous malignant etiology. The mammographic appearance of fat necrosis ranges from completely undetectable to a spiculated density and clustered microcalcifications. Many authors believe that the calcifications of fat necrosis can be distinguished from those seen with breast malignancies. Ultrasonographic findings include a solitary cyst, heterogenous echogenicity, and microcalcifications. Any remaining doubt as to the biologic nature of the mass should then be pursued with needle or open biopsy of the mass.
Injection of any agent into the mass before it is definitively diagnosed is contraindicated, as is surgical removal or observation without obtaining a confident exclusion of malignancy.
Referral to an oncologist would be premature in this instance and would provoke an unnecessary level of patient anxiety.
2016
A 56-year-old woman undergoes bilateral reduction mammaplasty. Eight hundred grams per breast is removed and sent to permanent pathology. Which of the following results most likely requires further discussion with a breast surgeon?
A) Apocrine metaplasia B) Atypical lobular hyperplasia C) Fibroadenoma D) Papillomatosis E) Sclerosing adenosis
The correct response is Option B.
All of the answers are examples of benign breast disease. However, atypical lobular hyperplasia (ALH) is associated with an increased risk for breast cancer. Depending on other patient risk factors, chemoprevention with anti-estrogen medications and increased surveillance may be recommended.
2016
A 47-year-old woman undergoes bilateral reduction mammaplasty surgery. Pathologic analysis of the resected breast tissue shows atypical ductal hyperplasia in the left breast. Which of the following is the most appropriate next step in management?
A) Gail model risk assessment
B) Hormonal therapy with aromatase inhibitors
C) Hormonal therapy with selective estrogen receptor modulators
D) Left-sided mastectomy
E) Postoperative radiation therapy
The correct response is Option A.
Atypical ductal hyperplasia is a risk factor for breast cancer in both the ipsilateral and contralateral breast, although the risk for the ipsilateral breast is higher. There is an approximately three-fold to five-fold increase in the risk for breast cancer in patients who have had biopsy-proven atypia. In an excisional biopsy, no additional surgery is needed for a finding of atypia; this is in distinction to atypia found on core biopsy, in which excision is recommended. In neither case is mastectomy indicated.
Radiation therapy is indicated for positive surgical margins in breast cancer excision, tumor size greater than 5 cm, more than four positive axillary nodes, and T4 disease.
The finding in this scenario should prompt the practitioner to perform a full risk assessment. Although the Gail model has been criticized for underestimating the risk for cancer in the context of atypical hyperplasia, it is still the most appropriate choice of the options listed. If the risk for breast cancer is sufficiently high after all factors are considered, hormonal therapy as a preventive measure may be indicated.
2016
A 45-year-old woman, gravida 3, para 3, undergoes reduction mammaplasty. Pathologic examination of excised tissue shows a completely excised, 1-cm papilloma. Which of the following is the most appropriate next step in management?
A) External radiation therapy B) Mammography C) Sentinel lymph node biopsy D) Subcutaneous mastectomy E) Tamoxifen therapy
The correct response is Option B.
The management of papillomas found on breast core needle biopsy specimens is controversial. The concern is malignancy, and some institutions have reported false-negative rates in biopsy. The presence of atypia is an indication for complete excision, and is also associated with a final upstaging to in situ or invasive carcinoma. For these reasons, excisional biopsy is recommended for lesions found on core needle biopsy. In this case, the lesion was completely excised, which is the most aggressive treatment. Because the final pathology was benign disease, this excision is adequate.
A subcutaneous mastectomy is not necessary, and a sentinel lymph node biopsy is not indicated because the pathology is benign. Similarly, tamoxifen treatment and external radiation therapy are not indicated for this benign condition.
2016
A 45-year-old woman comes to the office because she is interested in having reduction mammaplasty. She asks if undergoing reduction mammaplasty would decrease her risk of breast cancer. Which of the following is the most appropriate response to this patient?
A) The rate of breast cancer has been shown to be slightly increased in patients who undergo reduction mammaplasty
B) Reduction mammaplasty appears to decrease the rate by 90%
C) Reduction mammaplasty decreases the rate of breast cancer but less than prophylactic mastectomies
D) There is no evidence that reduction mammaplasty decreases cancer risk
The correct response is Option C.
Over the past decade, several large retrospective studies have looked at the rate of developing breast cancer after reduction mammaplasty. The breast cancer rates in patients undergoing reduction mammaplasty have consistently been decreased by about 30%. This differs from prophylactic mastectomy, which lowers the rate by as much as 90%.
2015
An otherwise healthy 17-year-old nulliparous girl is evaluated because of significant breast asymmetry. She has noted an increase in the size of her left breast over the past 2 months. Current medication includes a combined oral contraceptive. The patient undergoes mammography and biopsy. Pathologic examination of excised tissue shows a benign phyllodes tumor. Which of the following is the most appropriate next step in management?
A) Enucleation B) Mastectomy with sentinel lymph node biopsy C) Progestin-only oral contraceptive D) Tamoxifen followed by lumpectomy E) Wide local excision
The correct response is Option E.
The three most common causes for adolescent unilateral breast enlargement are giant fibroadenoma, phyllodes tumor (previously called cystosarcoma phyllodes), and juvenile breast hyprterophy.
Differentiation between phyllodes tumor and giant fibroadenoma on core needle biopsy is difficult. Phyllodes tumors are fibroepithelial tumors and stromal derived. The stromal component can appear similar to a fibroadenoma, and this similarity can make the two difficult to distinguish; in some cases, the stromal component resembles a soft-tissue sarcoma. Core needle biopsy is performed for diagnosis, and phyllodes tumors typically have increased cellularity, mitosis, and stromal overgrowth when compared with fibroadenomas.
Phyllodes tumors of the breast represent approximately 3% of breast neoplasms. They are classified as benign, borderline, or malignant. Wide excision with 1-cm margins is recommended for all classifications. The extent of resection is determined by the grade, and the grade is associated with the risk of local recurrence.
Margin-negative, breast-conserving therapy is appropriate for benign phyllodes tumors. Malignant phyllodes tumors behave more similarly to sarcomas than to other types of breast cancer. Although there is controversy about the role of radiation therapy, this modality is less effective than surgery, and is reserved for margin-positive, malignant tumors. Chemotherapy is not indicated in this patient. The greatest risk with benign phyllodes tumors is local recurrence, and overall, the prognosis of these tumors is considered excellent.
The only known condition associated with the development of phyllodes tumors is Li-Fraumeni syndrome.
2015
A 16-year-old girl comes to the office with her parents because she would like reduction mammaplasty surgery. Height is 5 ft 1 in (155 cm) and weight is 160 lb (72.6 kg). She wears a size 36G brassiere and her breast size has remained the same for the past year. She has significant physical manifestations of macromastia. Her parents report that she does not want to go to work or school because she is embarrassed by the size of her breasts. Which of the following is the most appropriate management of this patient’s condition?
A) Defer reduction mammaplasty until the patient has lost at least 20 lb (9.1 kg)
B) Defer reduction mammaplasty until the patient is at least 22 years of age
C) Perform reduction mammaplasty
D) Refuse to perform surgery until the patient is evaluated by a psychiatrist
The correct response is Option C.
Breast hypertrophy can affect girls as young as 10 to 15 years old and can result in massive breast development that can have profound physical and psychological impact on the patient. Reduction mammaplasty is indicated for these patients, despite the risk of breast growth postoperatively, which may necessitate a secondary operation. As long as the patient has a mature attitude, understands the permanence of the scars involved, and has parents who are supportive of her decision, then surgery should not be delayed simply to wait until the patient reaches a certain age. The large breasts are already a major problem and further growth will compound the problem and make it difficult to manage later.
With the rise in childhood obesity, there has been an increase in the number of patients seeking adolescent reduction mammaplasty. The cause of macromastia in pubertal and parapubertal girls is variable and includes endocrine changes, childhood obesity, and juvenile (virginal) hypertrophy of the breast. Benefits of reduction mammaplasty include resolution of pain, improved quality of life, extroversion, and emotional stability.
Reduction mammaplasty has been clearly proven to decrease the physical manifestations associated with macromastia, regardless of height and weight, as well as provide psychosocial benefits and improve self-esteem, regardless of age of patient.
2015
Reduction mammaplasty using which of the following pedicles has the greatest risk of altered nipple sensation?
A) Inferior B) Inferocentral C) Lateral D) Superior E) Superomedial
The correct response is Option D.
Reduction mammaplasty with a superior pedicle that involves resection of the tissue at the base of the breast is associated with a higher risk of injury to the nerve branches that innervate the nipple-areolar complex. Innervation from the lateral cutaneous branches runs deep within the pectoral fascia before sharply turning in an anterior direction to innervate the nipple from its deep aspect.
The lateral pedicle, inferior pedicle, and inferocentral pedicle save the tissue containing the lateral cutaneous branches, decreasing the chance for injury to this nerve and reduced nipple sensation. The superomedial pedicle preserves the anterior cutaneous branches which run superficially from the medial aspect of the breast, and also provide sensation to the nipple. The superior pedicle resects both the medial and lateral innervations to the nipple.
2015
An otherwise healthy 44-year-old woman comes to the office for reduction mammaplasty consultation. She wears a size 44DD brassiere. Physical examination shows rashes underneath the breasts, shoulder grooving from brassiere straps, and shoulder pain. A reduction is planned with removal of 500g of tissue bilaterally. The woman reveals that her sister underwent reduction mammaplasty with a much larger resection size and questions whether she will have the same relief of symptoms. Which of the following is the most appropriate response?
A) Larger reductions are associated with less marked relief of symptoms
B) Larger reductions are associated with more marked relief of symptoms
C) Smaller reductions are associated with less marked relief of symptoms
D) Smaller reductions are associated with more marked relief of symptoms
E) Resection size is not associated with relief of symptoms
The correct response is Option E.
The ASPS has a clinical guideline summary on reduction mammaplasty, based on the available evidence. Although insurance companies often use resection weight as a criterion for coverage, resection weight is not necessarily associated with relief of symptoms; thus, predictions of relief of symptoms must be made based on the individual clinical picture. This evidence is graded B.
The risk of complications, however, does increase with resection weight (Grade B evidence). This risk of complications must be weighed against the potential for relief of symptoms with large resection weights. A distinction is made between resection weight and BMI. The ASPS guideline found only “inconclusive” data on the association between BMI and the risk of complications.
2014
Which of the following best describes the role of estrogen in breast function?
A) Decreases cell division B) Decreases fibrocystic changes C) Facilitates ductal growth D) Facilitates glandular growth E) Facilitates periductal stromal development
The correct response is Option C.
Breast development is a complex interplay of multiple factors. Estrogen and progesterone play a significant role in breast development—not only at puberty, but also during and after pregnancy, and during and after menopause. In general, estrogen causes ductal proliferation, while progesterone causes glandular proliferations. Progesterone is similarly responsible for periductal stromal development. Estrogen increases, not decreases, cell division, and is also associated with increased, not decreased, fibrocystic changes.
2014
A 5-ft 1-in (155-cm), 185-lb (84-kg), 45-year-old woman comes to the office for follow-up 1 week after she underwent reduction mammaplasty with a medial pedicle in the outpatient facility. BMI is 35 kg/m2. On examination, the right nipple-areola complex is dusky and cool. Nipple ischemia is suspected. Which of the following is the most appropriate next step in management?
A) Debridement of the necrotic nipple with primary closure
B) One-stage debridement of the necrotic nipple and reconstruction of the nipple-areola complex
C) One-stage exploration and conversion to a free nipple graft
D) Release of all insetting sutures
E) Observation only
The correct response is Option E.
Partial or total nipple necrosis may be one of the most devastating complications of reduction mammaplasty. The incidence of compromise of the nipple-areola complex is typically less than 5% after breast reduction. Increased BMI is a risk factor for and increased risk of both nipple necrosis and wound healing complications. Reduction mammaplasty is frequently performed on an outpatient basis. Patients are seen within a week of surgery for wound checks, but this may be too late to address a nipple with vascular compromise.
If nipple ischemia is noted at the time of surgery during inset, stitches should be released and vascularity reevaluated. An objective assessment of blood flow can be aided with the use of fluorescein injection and a Woods lamp, or with newer screening modalities that are currently being evaluated for this purpose. While inset may be reattempted, the patient will likely require conversion to a free nipple graft. The nipple should be grafted to well-vascularized, deepithelialized dermis and not to ischemic fat that may be part of the compromised pedicle.
If nipple ischemia is detected in the early postoperative period, and there is no hematoma or issue with external compression, the nipple should be released from its inset position. This will relieve tension on the pedicle. If the nipple does not improve, the patient is taken back to the operating room for free nipple grafting.
If nipple ischemia is not identified in the early postoperative period, the patient should be treated with conservative wound care until healing is complete. Nipple reconstruction can then be undertaken in a delayed manner.
2013
A 45-year-old woman comes to the office for consultation regarding reduction mammaplasty because of pain of the neck and upper back. She currently wears a size 42 DDD brassiere and would like to be a C cup. A vertical reduction mammaplasty with a superomedial pedicle is planned. Which of the following is the dominant blood supply for this pedicle?
A) Ascending branch from the fifth intercostal space
B) Ascending branch from the sixth intercostal space
C) Descending branch from the first intercostal space
D) Descending branch from the second intercostal space
E) Descending branch from the fourth intercostal space
The correct response is Option D.
Almost 60% of the blood flow to the breast is from the internal mammary artery. The second and third anterior perforating branches are most dominant. In a superomedial pedicle both the second and third descending branches are captured in the pedicle. In a pure medial pedicle, it is usually the third. The other branches do not constitute any significant contribution to the pedicle blood supply in a superomedial or medial reduction.
2013
A 16-year-old girl is referred to the office because of an 8-month history of sudden and rapid enlargement of the right breast. She reports no other symptoms. Physical examination shows a large, palpable mass on the lower half of the right breast. Marked nipple-areola complex stretching, prominent dilated veins, and skin ulceration inferolateral to the mass are noted. Mammography and ultrasonography show a dense, circumscribed, homogenous 8-cm mass in the right breast. Which of the following is the most likely diagnosis?
A) Carcinoma B) Cyst C) Giant fibroadenoma D) Juvenile breast hypertrophy E) Phyllodes tumor
The correct response is Option C.
This patient has a fibroadenoma, the most common breast neoplasm in adolescent females. Giant fibroadenomas are typically solitary, firm, nontender, and symptoms include a rapid asymmetric breast enlargement with prominent overlying veins and occasional pressure-induced skin ulceration. These lesions are larger than 5 cm and occur at or soon after the onset of puberty. These lesions are typically treated with enucleation using reduction mammaplasty techniques for optimal symmetry with the contralateral breast. Mastectomy is not indicated, and no other adjuvant therapy is necessary. Smaller fibroadenomas may be watched conservatively, with minimal risk of malignant transformation. Surgical intervention is indicated in cases of mastodynia, neck/back pain secondary to large size, difficulty with clothing due to asymmetry, and to alleviate patient concern.
Carcinoma would be unlikely in this age demographic. The differential diagnosis would additionally include cystic enlargement, breast hypertrophy, or phyllodes tumor.
Juvenile breast hypertrophy may occur as unilateral or bilateral breast enlargement. The enlargement is diffuse without evidence of a discrete mass or nodularity. Juvenile breast hypertrophy typically occurs in early puberty, rarely regresses spontaneously, and is much more severe than simple breast hypertrophy. The underlying cause is attributed to estrogen stimulation at the onset of the first menses. Treatment is reduction mammaplasty.
Phyllodes tumors are large, benign tumors that typically occur in the perimenopausal patient. They are histologically distinct from fibroadenomas, and transformation of a fibroadenoma to a phyllodes tumor is exceptionally rare.
2012
A 37-year-old woman comes for evaluation of symptomatic macromastia after failure of conservative treatment. Height is 5 ft 4 in (163 cm) and weight is 245 lb (111 kg). BMI is 42 kg/m2. Physical examination shows Grade II ptosis and symmetrical macromastia. The estimated weight of tissue resection is 1200 g per side. An inferior pedicle reduction mammaplasty is planned. Which of the following places this patient at greatest risk for postoperative hematoma?
A) Hypotensive general anesthesia B) Obesity C) Omitting closed suction drains D) The patient's age E) Weight of the resected specimen
The correct response is Option A.
The risks associated with reduction mammaplasty include local complications such as healing problems, nipple necrosis, loss of nipple sensitivity, infection, hematoma, hypertrophic scarring, fat necrosis, and asymmetry; systemic effects include deep venous thrombosis, pulmonary embolism, atelectasis, and a number of other surgical and anesthesia-related complications.
The quantified risk of complications resulting from reduction mammaplasty increases with the weight of the resected specimen. These include wound-healing problems and nipple sensitivity. Some authors have recommended that normotensive anesthesia be administered throughout the procedure.
While local and systemic risks are associated with elevated BMI, the degree of obesity does not demonstrate a correlation between risks and elevated body weight. The rate of hypertrophic scarring was shown to decrease with larger resections, possibly because of relief of skin tension or the presence of attenuated dermal thickness.
Intraoperative hypotension, utilized to diminish blood loss during surgery, results in a higher rate of subsequent hematoma. Randomized studies documenting the risk of hematoma have shown no difference between patients with and without the use of closed suction drains.
2012
A 15-year-old girl is brought to the office because her breasts have enlarged rapidly. She says she has severe back pain and posture problems. Her parents report that her brassiere size increased from 34B to 34E at age 13 years. There has been no increase in size for the past 12 months. Height is 5 ft 5 in (165 cm) and weight is 140 lb (63 kg). Which of the following is the most appropriate management?
A) Antiestrogen hormone therapy
B) Diet and exercise program to lose 15 lb (6.8 kg)
C) Reduction mammaplasty
D) Six-month testosterone injection protocol
E) Observation until the patient is age 18 years
The correct response is Option C.
The accurate diagnosis of benign pediatric breast tumors is essential for proper treatment. When bilateral enlargement that is grossly out of proportion occurs at menarche, it is termed juvenile hypertrophy. After the enlargement has stabilized for approximately 1 year, the treatment is surgical. There is only anecdotal evidence for using antiestrogen hormone therapy (Tamoxifen). Proper diet and exercise would be expected to reduce the size slightly, but the usual resection in these cases is 1800 g or more.
The use of testosterone injection is not indicated for juvenile hypertrophy.
Observation, while indicated at first to allow the process to be fully manifested, would be appropriate after the size had stabilized for about a year. Then it would be appropriate for the surgeon to reduce the size if necessary. The differential diagnosis for pediatric breast enlargement includes fibroadenomas, phyllodes tumor, and cancer.
2012
An 8-year-old girl is brought to the office by her mother because her daughter’s breasts have begun to develop. The mother says that her daughter has no history of serious illness. Height is 4 ft 2 in (127 cm, in 50th percentile) and weight is 55 lb (25 kg, in 50th percentile). Physical examination shows that her current cup size is a B. No pubic hair or vaginal mucosal thickening is noted. Which of the following is the most likely diagnosis?
A) Benign premature thelarche B) Cushing syndrome C) Gynecomastia D) McCune-Albright syndrome E) Precocious puberty
The correct response is Option A.
Knowledge of normal puberty and abnormal conditions of puberty is critical for any plastic surgeon evaluating the pediatric breast.
Tanner staging requires evaluation of pubic hair (males and females), genitals (males), and breasts (females). Because the patient described lacks pubic hair (Tanner I) and vaginal mucosal thickening, she has not started puberty in other areas. This excludes precocious puberty. If breasts develop before puberty has begun in other areas, it is considered benign premature thelarche and requires no intervention.
Gynecomastia is a hyperplastic condition of breast tissue. The patient described does not have hyperplastic breasts. In one series, hyperplastic breast abnormalities such as gynecomastia were the most common indication for operative intervention, with an average age of operation in the late teens.
McCune-Albright syndrome, also known as polyostotic fibrous dysplasia, is a condition characterized by premature puberty. Patients often begin menstruation before breast development. Patients also develop bony abnormalities, gigantism, and café-au-lait spots.
2012
A 38-year-old woman, gravida 2, para 2, is scheduled to undergo reduction mammaplasty because of pain in the neck and shoulders. She wears a size 44E brassiere. Physical examination shows pendulous breasts. The sternal notch-to-nipple distance is 40 cm. Hypertrophy of which of the following muscles is most likely in this patient?
A) Latissimus dorsi B) Levator scapulae C) Pectoralis major D) Rhomboid major E) Trapezius
The correct response is Option E.
Each of the muscles described is an extrinsic muscle of the back. The trapezius elevates the scapula in squaring the shoulders, and the superior, middle, and inferior fibers act together to pull the scapulae posteriorly, bracing the shoulders. The latissimus extends, adducts, and medially rotates the humerus. The levator scapulae elevate the scapula and rotate the glenoid cavity inferiorly, and the rhomboid major and minor together retract the scapula and fix the scapula to the thoracic wall.
In mammary hypertrophy, the downward pull of the breasts rotates the shoulders forward, requiring significantly more work of the shoulder girdle muscles. It is the unique function of the trapezius to ?square? the shoulders that makes it most vulnerable in mammary hypertrophy; because of the extra work this requires, it often becomes hypertrophic.
Patients often complain of shoulder, neck, and upper back pain as a result of the trapezius strain.
2011
A 25-year-old woman is scheduled to undergo breast reduction with resection of 2.4 lb (1100 g) from each breast. Current weight is 200 lb (91 kg), and height is 5 ft 8 in (173 cm). Physical examination shows macromastia with nipple-sternal notch distance of 34 cm on the left and 35 cm on the right. A photograph is shown - VERY large breasts. Which of the following postoperative complications is most likely in this patient?
A) Bleeding B) Fat necrosis C) Infection D) Seroma E) Wound breakdown
The correct response is Option E.
Breast reduction is one of the most commonly performed procedures in plastic surgery, and outcomes following breast reduction have been well studied. Common risks associated with breast reduction include infection, symptomatic scar, seroma, wound healing complications, fat necrosis, asymmetry, and need for reoperation. BMI, volume of breast tissue resection greater than 1000g per breast, and tobacco use are the greatest risk factors for complication following surgery. Wound healing complications are more likely to occur following breast reduction in a young, healthy, but obese patient with large resection volumes. Other complications might occur but are less common. None of the other complications have been associated with risk factors.
2011
A 43-year-old woman is undergoing bilateral reduction mammaplasty with the inferior pedicle technique. The dermis is preserved during deepithelialization of the pedicle to protect which of the following anatomical structures?
A) Perforators from the internal mammary artery
B) Perforators from the lateral thoracic artery
C) Sebaceous glands
D) Subdermal plexus
E) Superficial layer of the superficial fascia of the breast
The correct response is Option D.
The major blood supply to the breast comes from perforating branches of the internal mammary artery, lateral branches of the posterior intercostal arteries, and branches of the axillary artery. The blood supply from the axillary artery includes the pectoral branches, the highest thoracic artery, and the lateral thoracic artery. Those vessels from the pectoral branches enter underneath the muscle before coming through it to supply the breast tissue. The vessels from the lateral thoracic artery, known as the lateral mammary branches, wrap around the lateral border of the pectoralis muscle to supply the lateral breast. The second, third, and fourth perforating branches from the internal mammary artery, known as the medial mammary arteries, enter the medial aspect of the breast. The perforating branches from the second, third, and fourth posterior intercostal arteries, known as the mammary branches, enter the breast laterally. The vascular arcades seem to be concentrated at the periphery of the breast (the cutaneoglandular plexus), and the larger vessels appear to lie not far beneath the skin, superficial to the glandular tissue. This finding has led certain authors to conclude that resection of the gland should not commence fewer than 2 to 3 cm from the chest wall; if skin flaps are elevated, they should be kept at least 2 cm thick for maximum viability. This also justifies preservation of the dermis when deepithelializing flaps to protect the subdermal plexus from injury.
Perforators from the internal mammary artery and lateral thoracic artery supply the breast parenchyma. The superficial layer of the superficial fascia of the breast parenchyma does not provide vascularity.
2011
Which of the following arteries is the dominant blood supply to the nipple-areola complex?
A) Axillary B) Internal mammary C) Subclavian D) Superficial epigastric E) Thoracodorsal
The correct response is Option B.
Multiple studies have been performed to document the blood supply to the breast and the wide range of normal. The nipple-areola complex receives its blood supply from the mammary arteries, which are a branch of the subclavian artery. The subclavian artery becomes the axillary artery and gives off the thoracodorsal artery. The superficial epigastric artery supplies the upper abdomen. The mammary arteries are sometimes referred to as the thoracic arteries.
2011
A 16-year-old girl is referred by her pediatrician for mammaplasty because of breast hypertrophy that has worsened during the past 2 years. She wears a size 36DD brassiere and has constant pain in the shoulders and back due to the weight of her breasts. Menarche occurred at 10 years of age. Height is 5 ft 4 in (163 cm), and weight is 165 lb (75 kg). Physical examination shows breast hypertrophy, shoulder grooving, intertrigo dermatitis, and striae. An abnormality of which of the following is the most likely cause of this patient’s condition?
A) End-organ responsiveness to estrogen B) Number of estrogen receptors C) Progesterone concentration D) Prolactin concentration E) Serum estrogen concentration
The correct response is Option A.
Abnormal end-organ responsiveness to estrogen is the predominant factor leading to breast hypertrophy. It has been demonstrated that normal levels of estrogen, progesterone, and prolactin exist in patients with breast hypertrophy. These patients also have a normal number of estrogen receptors.
2011
A 33-year-old woman comes to the office because of a new lump in her right breast 6 weeks after undergoing bilateral reduction mammaplasty using the inferior pedicle technique. Preoperative examination of the breasts showed no abnormalities. Current examination shows a hard, nontender mass in the lateral aspect of the upper right breast. Which of the following is the most likely diagnosis?
A ) Abscess B ) Fat necrosis C ) Fibroadenoma D ) Hematoma E ) Seroma
The correct response is Option B.
A patient presenting with a hard, nontender lump 6 weeks after reduction mammaplasty is most likely to have fat necrosis. This is usually the result of vascular compromise to areas of the parenchyma associated with hemorrhagic necrosis. Drainage from fat liquefaction is often the first sign of infection. Cellulitis and fever may then result. Small areas of fat necrosis can be managed conservatively, and secondary revision can be performed after a period of 6 months to 1 year. If skin and fat necrosis is extensive and associated with an infection, surgical debridement and antibiotics are required. Secondary closure and grafting are required after the infection has resolved.
An abscess or hematoma would be firm but likely tender. Fibroadenoma would not likely be palpable so early postoperatively. However, if the lump does not resolve within a few weeks, CT scan or ultrasonography should be considered to rule out malignancy. Seroma would most likely have a softer consistency.
2010
An otherwise healthy 33-year-old woman comes to the office because of back pain, brassiere grooving, and an inframammary rash. She wears a size 42 L brassiere. She has one child and says she would like to have more children. BMI is 33 kg/m2. The distance from nipple to sternal notch is 37 cm bilaterally, and the distance from nipple to inframammary fold is 16 cm bilaterally. A photograph is shown. Which of the following is the most appropriate reduction mammaplasty technique for this patient?
A ) Inferior pedicle with Wise skin pattern
B ) Lower pole amputation with nipple grafting
C ) Medial pedicle with vertical skin pattern
D ) Superior pedicle with vertical skin pattern
E ) Superior pedicle with Wise skin pattern and nipple grafting
The correct response is Option A.
The patient described is a young, healthy woman, who may desire to have more children later in life, making nipple preservation an optimal choice. She is large in size and has ptosis, making an inferior pedicle with Wise pattern the best technique to ensure adequate tissue removal. This technique is also able to reduce the vertical dimension of the breast, which is more challenging with vertical skin pattern reduction mammaplasty. Inferior pedicle reduction mammaplasty can achieve significant reduction in breast volume and alleviate preoperative symptoms with a low risk of complications.
Nipple grafting techniques are unnecessary in this woman, whose nipple needs to be elevated only 13 to 16 cm, and who may desire to have another child in the future. Medial pedicle technique is not widely used. It has been described with limited incision techniques and in combination with Wise pattern for severe macromastia. Limited incision techniques might fail to achieve reliable reduction in breast volume and result in aesthetic dimensions as well. These vertical scar techniques are best reserved for smaller volume reductions.
2010
A 14-year-old girl comes to the office with a history of rapid significant increase in the size of her breasts with puberty. She wears a size 32H brassiere. The size of her breasts negatively affects her activities of daily living. Physical examination shows BMI is 21 kg/m2, and both breasts are enlarged with minimal asymmetry. Histology of the breasts is most likely to demonstrate a proliferation of which of the following types of tissue?
A) Adipose B) Ductal C) Lobular D) Muscle E) Stromal
The correct response is Option E.
The patient is presenting with juvenile (virginal) hypertrophy of the breast. In this patient, the growth of the breast is due to the hypertrophy of the stromal component of the breast tissue. In this case, the patient has a normal range BMI, decreasing the chances that the size of the breast is related to her weight.
The histology of the breast will demonstrate a predominance of stromal tissue. This is the connective tissue of the breasts, which includes the fibroblasts and fat. As noted, fatty tissue will be present in the breast; however, it is not a predominant component in true juvenile massive breast enlargement as compared with breast enlargement in the obese adolescent. Ducts will be present but not predominating, lobules will be absent or poorly formed, and muscle development is unrelated to breast size.
2019
The dominant blood supply to the nipple-areola complex comes from which of the following arteries?
A) Anterior lateral intercostal B) Internal mammary C) Lateral thoracic D) Superior epigastric E) Thoracoacromial
The correct response is Option B.
Although the internal mammary artery, anterior intercostal arteries, lateral thoracic arteries, and thoracoacromial artery all supply the nipple-areola complex (NAC), the internal mammary artery provides the most consistent contribution, which has been confirmed in multiple cadaver studies as well as in vivo MRI studies. The superior epigastric artery arising from the internal mammary artery supplies the anterior abdominal wall.
Indeed, some authors have suggested that the decreased incidence of NAC necrosis with an inframammary fold incision when compared with a periareolar incision may be due to the preservation of the blood supply to the NAC using the former incision. The design of pedicles for reduction mammaplasty, similarly, has been historically informed by the blood supply to the NAC.
2019
Which of the following arteries provides the blood supply to the superomedial pedicle in reduction mammaplasty procedures?
A) Internal mammary B) Lateral third intercostal C) Posterior fourth intercostal D) Thoracoacromial E) Thoracodorsal
The correct response is Option A.
The superomedial pedicle used in some reduction mammaplasty cases is supplied by arterial blood flow from the ipsilateral internal mammary artery and its intercostal branches. The other arteries are incorrect.
2019
A 53-year-old woman who underwent periareolar mastopexy 13 years ago comes to the office to request reoperation of her now DD-cup–sized breasts. She wants improvement in the appearance of her breasts with greater projection and a decrease in her brassiere size to a B cup. Physical examination of the breasts shows flattened nipple-areola complexes that are 72 mm in diameter surrounded by circumferential hypertrophic surgical scars. The breasts are wide and bottomed out with a 14-cm distance between the inferior areolar border and the inframammary fold. Which of the following is the most appropriate technique to achieve the desired result?
A) Liposuction of the breasts with autologous fat transfer to the retroareolar region
B) Liposuction of the breasts with placement of breast implants
C) Liposuction of the lower poles of the breasts with excision of the hypertrophic areolar scars
D) Periareolar mastopexy with open excision of excess breast tissue
E) Wise pattern mastopexy with open reduction of excess breast tissue
The correct response is Option E.
The most appropriate technique to achieve this patient’s desired result of improved appearance of her breasts with increased projection and significantly decreased cup size is a secondary Wise pattern mastopexy with open reduction of her excess breast tissue. This technique will allow reduction in the diameter of the areola, give increased breast projection, and decrease the chance for recurrence of widened hypertrophic periareolar scarring.
Liposuction of the lower pole of the breast and periareolar scar revision could modestly decrease breast volume and possibly improve scar quality, but they would be ineffective at improving breast shape and projection, and in decreasing the areolar dimensions and excessive length of the lower pole of the breast.
Periareolar mastopexy with open reduction of excess breast tissue will not increase central breast projection or adequately address the excessive length of the inferior areolar to inframammary crease distance.
Liposuction of the breasts with placement of breast implants could improve central breast projection. This approach, however, would not provide the significant decrease in breast volume of three cup sizes which this patient desires, and would not improve the patient’s periareolar scars or the bottoming out of the lower poles of the breasts.
Liposuction of the breasts with fat grafting to the retro-areolar areas could increase central breast projection and decrease brassiere cup size, but it does not treat the hypertrophic areolar scarring or the abnormal lower pole dimensions of the breasts.
2019
An otherwise healthy 52-year-old woman comes to the office for consultation for bilateral mastopexy. Her last mammogram 2 years ago was negative. Physical examination shows a palpable breast mass in the upper outer quadrant of the right breast that the patient has not noticed previously. Which of the following is the most appropriate next step in management?
A) Core needle biopsy B) Diagnostic mammogram with ultrasound C) Fine-needle aspiration biopsy D) Mastopexy with open biopsy E) Screening mammogram
The correct response is Option B.
The first step in the management of a newly found palpable breast mass is x-ray imaging to further characterize the tumor. The type of imaging required typically depends on the age of the patient at presentation. In females less than 30 years of age, ultrasound is typically the first (and possibly only) test ordered as the breast tissue is typically denser and mammography is not as effective. In women greater than 30 years of age, mammogram is usually the first test ordered. Mammography can evaluate both breasts for other incidental findings as well as further characterize the mass. Unless the results of the initial mammogram are definitive of a benign etiology of the mass, then an ultrasound is typically necessary as well. Ultrasound can distinguish cystic from solid masses and will help delineate the shape, borders, and acoustic properties of the mass. When the mass is suspicious, biopsy is guided by ultrasonography but this is typically not the initial treatment.
Mammography can be used for both screening and diagnosis. Screening mammography consists of two routine views, craniocaudal and mediolateral oblique, and is appropriate for asymptomatic patients. Diagnostic mammography incorporates additional views (e.g. tangential or spot compression views) in order to better delineate the area of concern. The current patient has a new finding of palpable mass on exam and requires a diagnostic mammogram for proper evaluation and management.
Given the patient’s age and presentation with newly palpable mass, x-ray imaging prior to any surgery is warranted to rule out malignancy. Proceeding with surgery that would rearrange the breast tissue may compromise the oncologic management of a possible breast cancer with incomplete excision and inability to obtain reliable margins that would require a completion mastectomy instead of the option for breast-conserving therapy.
2019
A 54-year-old woman with a history of left mastectomy for breast cancer presents for right reduction mammaplasty for symmetry. In this patient, the incidence of occult breast cancer discovered incidentally in tissue specimens at the time of reduction mammaplasty is approximately which of the following?
A) 0.4% B) 1% C) 5% D) 15% E) 23%
The correct response is Option C.
There have been multiple studies on the incidence of breast cancer discovered in reduction mammaplasty specimens. The incidence of occult cancer detected in reduction mammaplasty specimens is typically very low (0.06 to 5.45%) but varies depending on the patient’s age and history of breast cancer. One specific study compared women undergoing reduction mammaplasty for symptomatic macromastia with women undergoing reduction mammaplasty for symmetry after mastectomy with or without reconstruction. Incidentally discovering occult breast cancer was much higher in women undergoing symmetry procedures (5.5 vs. 0.4%) versus those undergoing reduction mammaplasty for symptomatic macromastia. The important distinction in this clinical vignette is that the woman has had a mastectomy for breast cancer, and highlights several important points including:
The importance of a thorough history before reduction mammaplasty
Preoperative clinical examination
Screening mammography prior to the reduction mammaplasty
Pathologic examination of reduction mammaplasty specimens
Based on multiple studies, the other percentages listed are either too high or too low.
The treatment of occult cancers discovered during reduction mammaplasty depends on several factors including family history and evaluation of surgical margins.
2019
