Breast Reduction / Gynecomastia Flashcards
Based on a systematic evidence review, which of the following is the most appropriate preoperative recommendation for women of average breast cancer risk undergoing reduction mammaplasty?
A) Annual mammography screening for women 45 to 54 years of age
B) Biennial breast MRI screening for women over age 55 years
C) BRCA testing
D) Establish a baseline mammogram for women over age 30 years
E) Screening breast thermography
The correct response is Option A.
The American Cancer Society 2015 guidelines for women undergoing reduction mammaplasty based on evidence-based medicine include: 1) annual screening for women aged 45 to 54 years; 2) biennial screening for women 55 years of age and older; 3) women aged 40 to 44 years have the opportunity to begin annual screening; 4) clinical breast examination is not indicated for cancer detection and surveillance. BRCA testing is currently recommended for high-risk familial inheritance concerns. Breast thermography and MRI are not used for screening patients of average risk.
A 32-year-old woman presents with symptomatic macromastia. Family history includes premenopausal breast cancer in her aunt. The patient is scheduled for bilateral reduction mammaplasty (using an inferior pedicle with wise pattern skin incision), and consent is obtained. During the procedure, a 3 × 3-cm area of suspicious tissue on the left upper outer quadrant is noted. Frozen section study confirms a 5-mm ductal carcinoma with free margins. Which of the following is the most appropriate next step in management of this patient?
A) Completion of reduction mammaplasty bilaterally, along with immediate left axillary sentinel node study
B) Completion of reduction mammaplasty bilaterally, along with routine orientation of the specimens, marking the cancer site with sutures and surgical metal clips
C) Completion of reduction mammaplasty bilaterally, followed by scheduling the patient for immediate adjuvant chemoradiotherapy
D) Completion of reduction mammaplasty bilaterally with excision of 3-cm extra margins of the cancer site
E) Completion of reduction mammaplasty on the right side, followed by left-sided mastectomy
The correct response is Option B.
The incidence of occult breast cancer detected by reduction mammaplasty is 0.06 to 5.45%. Management of the occult breast cancer depends on the history of breast cancer, surgical margin, and family history. Preoperative thorough history, clinical examination, and counseling regarding the risk for and implications of finding occult breast cancer are necessary. All women aged 35 years and older with positive family history or personal history of breast cancer should have a screening mammogram before surgery; if there is no family history, women aged 40 years and older should have a screening mammogram before surgery. Routine orientation of the specimens for pathologic analysis and en bloc resection should be performed in patients aged 30 years and older and in any patients with a personal or family history of breast cancer. Although mastectomy is the most common procedure performed after an incidental finding of occult breast cancer during reduction mammaplasty, multidisciplinary evaluation and tests are necessary before performing any surgical procedures (mastectomy, sentinel node study) or any plan for chemotherapy, hormone therapy, or radiation therapy. Also, lack of consent for other surgical procedures would prohibit the surgeon from adding another procedure at the time of breast reconstruction. Excision of the 3-cm extra margins is not the standard of care for 5-mm invasive breast cancer.
A 15-year-old girl is referred to the office because of a 7-month history of asymptomatic, rapid enlargement of the right breast. Physical examination shows a large, palpable mass occupying the lower half of the right breast. There is marked nipple-areola complex stretching and prominent dilated veins. Photographs are shown. Mammogram and ultrasound show a dense, circumscribed, homogeneous 15-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 fibroadenoma are typically solitary, firm, nontender, and present as a rapid asymmetric breast enlargement with prominent overlying veins and occasional pressure-induced skin ulceration. These lesions are larger than 5 cm and present at or soon after the onset of puberty. These lesions are typically treated with enucleation using breast reduction 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 for 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.
The differential diagnosis would include phyllodes tumor, breast hypertrophy, or cystic enlargement. Carcinoma would be unlikely in this age demographic. 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.
Juvenile breast hypertrophy may present as unilateral or bilateral breast enlargement. The enlargement is diffuse without evidence of a discrete mass or nodularity. Juvenile breast hypertrophy typically presents 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 mammoplasty.
A healthy 18-year-old woman presents for evaluation for reduction mammaplasty. Physical examination of the breasts shows a palpable area of fibrocystic tissue in the left axilla. The patient states that this tissue has been present since menarche and often becomes swollen and slightly tender during menses. Which of the following is the most likely developmental origin of this tissue?
A) Failure of mammary ridge involution
B) Hypertrophy of lactiferous duct formation
C) Incomplete mesodermal resorption
D) Overdevelopment of apocrine and sebaceous glands
The correct response is Option A.
Accessory breast tissue, or polymastia, results from incomplete involution of the ectodermal ridge outside the main mammary buds. During embryologic development, the breast forms from paired ectodermal ridges. Fifteen to twenty of these buds initially appear but then undergo apoptosis, leaving a pair of main mammary buds at the level of the fourth to fifth intercostal space. These mammary buds will become breasts. However, accessory breast tissue, such as in this patient, develops when a portion of the ectodermal ridges fails to involute during the seventh week of gestation. The other choices do not accurately describe the developmental origin of accessory breast tissue.
A 35-year-old woman undergoes bilateral reduction mammaplasty for treatment of symptomatic macromastia. Medical history includes chronic neck and back pain for 15 years. She wears a size 36H brassiere. The pathology specimen shows ductal carcinoma in situ completely excised with 2-mm margins. Postoperative MRI shows no additional abnormalities. Which of the following is the most appropriate next step to adequately treat this patient’s breast cancer?
A) Chemotherapy
B) Formal lumpectomy for adequate margins
C) Radiation therapy
D) Sentinel lymph node dissection
E) No additional treatment necessary
The correct response is Option C.
An incidental finding of breast cancer on breast reduction specimen final pathology can lead to significant anxiety for both the patient and the plastic surgeon. To mitigate this anxiety and provide the best care and support for the patient, plastic surgeons should be aware of the current guidelines for treatment of breast cancer. In this patient, there are two viable options for adequate treatment similar to most breast cancers after the diagnosis is confirmed by biopsy with equivalent 5-year survival rates: lumpectomy and adjuvant radiation versus completion mastectomy. Ductal carcinoma in situ (DCIS) requires excision with margin greater than or equal to 2 mm for adequate extirpation. Because this patient has adequate margins with the breast reduction specimen, she would only require adjuvant radiation therapy unless she elects to have completion mastectomy with or without reconstruction. Chemotherapy is reserved for invasive tumors with potential systemic spread. Sentinel lymph node dissection is not required with in situ cancers that are noninvasive.
A 45-year-old woman presents for consultation for reduction mammaplasty. On examination, a 1-cm mass in the upper outer quadrant is noted. Which of the following is the most appropriate initial imaging test for this patient?
A) Diagnostic mammography
B) MRI
C) Positron emission tomography
D) Sestamibi scan
E) Thermography
The correct response is Option A.
Diagnostic mammography is the initial imaging modality of choice for a clinically detected palpable breast mass in a woman aged 40 years or older. For a woman under the age of 30 years, breast ultrasonography would be the first choice. For a woman aged 30 to 39 years, either modality would be acceptable for initial evaluation. It is essential that there be correlation between the imaging and area of palpable concern to confirm the correct finding is being evaluated. Regardless of palpable findings, any highly suspicious breast mass that is detected by imaging warrants biopsy. Further, any highly suspicious breast mass that is detected by palpation warrants biopsy. Thermography has not been approved for screening.
An otherwise healthy 29-year-old woman is scheduled to undergo bilateral reduction mammaplasty. Medical history includes symptomatic macromastia and significant breast hypertrophy. The operative plan includes a Wise pattern, inferior pedicle breast reduction, and infiltration of the incisions and parenchyma with a dilute epinephrine solution at a concentration of 1:500,000. The benefit of infiltration of the operative sites is to decrease which of the following?
A) Intraoperative blood loss
B) Operative time
C) Postoperative drainage
D) Risk of hematoma
E) Risk of infection
The correct response is Option A.
The use of epinephrine-containing wetting solutions has been used extensively in plastic surgery to minimize blood loss complications in many types of surgery, including breast reduction. Injection of a dilute epinephrine wetting agent can significantly reduce blood loss. No change in operative time, risk for infection, hematoma or postoperative bleeding, or drainage outputs has been shown.
A 52-year-old woman undergoes preoperative mammogram. Medical history includes symptomatic macromastia. Suspicious calcifications are identified, and a core-needle biopsy is performed. Which of the following results necessitates an excisional biopsy prior to proceeding with the reduction mammaplasty?
A) Atypical lobular hyperplasia
B) Fibroadenoma
C) Papilloma without atypia
D) Pseudoangiomatous stromal hyperplasia
E) Radial scar
The correct response is Option A.
National Comprehensive Cancer Network (NCCN) protocol recommends excisional biopsy following detection of the following high risk lesions: papillomas with atypia, atypical ductal hyperplasia (ADH), atypical lobular hyperplasia (ALH), and ductal carcinoma in situ (DCIS). These lesions, initially diagnosed on vacuum-assisted core-needle biopsy, progress to carcinoma of the breast on excisional biopsy in 10% to 39% of cases. Also, any proliferative lesion with atypia or any biopsy result that is discordant with its radiologic image should also undergo excisional biopsy. If a radial scar has been completely excised and definitively diagnosed, it does not require an excisional biopsy.
Once a lesion has been confirmed benign, it is safe to proceed with reduction mammaplasty. It is important to note that a woman with a history of ADH, ALH, or lobular carcinoma in situ (LCIS) will have an increased risk for developing in situ or invasive breast carcinoma over her lifetime. These patients should, at a minimum, undergo yearly mammographic screening as well as possible breast magnetic resonance imaging and risk reducing strategies including endocrine therapy.
Pseudoangiomatous stromal hyperplasia (PASH) is a benign breast lesion characterized histologically by dense collagenous stroma with spindle cell-lined spaces that appear like capillaries. Microscopic disease may be found incidentally, or it may be associated with a palpable mass. It has not been demonstrated to increase risk for subsequent breast carcinoma development.
Which of the following is the dominant blood supply to the nipple-areola complex in a superomedial pedicle breast reduction?
A) Anterior lateral perforators
B) Dermal plexus
C) Internal mammary perforators
D) Lateral thoracic system perforators
The correct response is Option C.
The vascular supply to the nipple areola complex in a superomedial breast reduction is perforators of the internal mammary artery.
Anterior lateral perforators are divided during superomedial pedicle technique.
Lateral pedicle (Skoog technique) is relied on lateral thoracic system perforators.
Dermal plexus could be perfuse by any of the above arteries but it finally depends on which artery has not been sacrificed during the creation of the pedicle. In superomedial pedicle technique, the lateral thoracic and anterior intercostals have been already sacrificed.
References
A 45-year-old woman with macromastia presents for breast reduction surgery. BMI is 34 kg/m2. Physical examination shows grade III ptosis with bilateral bra strap grooving. A photograph is shown. Breast reduction mammaplasty of approximately 1000 g per breast using a Wise pattern and inferior pedicle technique is planned. Which of the following factors is most likely to increase this patient’s risk for perioperative complications?
A) BMI
B) Degree of ptosis
C) Inferior pedicle
D) Resection volume
E) Wise pattern
The correct response is Option D.
According to the Breast Reduction Assessment: Value and Outcomes (BRAVO) study, the overall complication rate for breast reduction was 43% with delayed healing as the most common. This complication was correlated directly with average preoperative breast volume, average resection weight/breast, and smoking, and was correlated inversely with age. Analysis associated resection weight as the sole variable for increased risk of complications and with absolute number of complications (greater than 847 g). Each 10-fold increase in resection weight increased the risk of complication 4.8 times and increased the risk of delayed healing 11.6 times. Degree of ptosis was not correlated with delayed healing. Vertical incision techniques were associated with an increased complication frequency without a link to specific complications.
A previously healthy 13-year-old girl is brought to the clinic because of a painful and progressively enlarging axillary mass. Examination of a specimen previously obtained on biopsy showed hyperplastic glandular tissue without cytological atypia in the reticular dermis and subcutaneous tissue. Which of the following is the most likely diagnosis?
A) Accessory mammary tissue
B) Fibroadenoma
C) Juvenile hypertrophy
D) Juvenile papillomatosis
E) Lipoma
The correct response is Option A.
Accessory breast tissue typically occurs along the embryonic milk line and often enlarges during periods of hormonal stimulation, such as puberty. The rapid enlargement can be associated with pain. Histopathology shows glandular tissue and receptor staining is positive for estrogen and progesterone.
Fibroadenoma presents as a firm, rubbery nodule, usually within the ectopic breast, and histopathology shows epithelial and stromal proliferation.
Juvenile hypertrophy is progressive enlargement of the breasts during puberty, defined as greater than 3% of total body weight or greater than 3.3 lb (1500 g). Histopathology is similar to gynecomastia, with increased stromal collagen and fat.
A lipoma can present similarly to ectopic mammary tissue but histopathology would show mature adipose tissue.
Juvenile papillomatosis (“Swiss cheese disease”) was first described in 1980 and presents clinically similar to a fibroadenoma. Papillomatosis and epithelial hyperplasia, as well as sclerosing adenosis and cysts, are characteristic on histopathology. Approximately 10% of patients with juvenile papillomatosis will develop a malignancy. Although it occurs in pediatric patients, it is actually more common in adults.
A 35-year-old woman with symptomatic macromastia comes to the office to request bilateral reduction mammaplasty. She reports no history of breast biopsy or prior chest surgery. BMI is 25 kg/m2. Physical examination shows grade II ptosis with loss of upper pole fullness and good skin laxity, thus the decision is made to perform a bilateral reduction mammaplasty using a superomedial pedicle technique. Which of the following is the dominant blood supply to the nipple after this procedure?
A) Acromiothoracic artery
B) Lateral thoracic artery
C) Perforators of the internal thoracic artery
D) Posterior intercostal arteries
E) Superficial thoracic artery
The correct response is Option C.
The major blood supply from a superomedial pedicle to the nipple is the first through fourth perforators of the internal thoracic artery. The perforators originate from the first through fourth interspaces. The second perforating branch is considered the principal vessel.
While these vessels form anastomoses with branches from the lateral thoracic artery, the anastomoses are severed in the process of forming the superomedial pedicle.
The acromiothoracic artery does supply the skin arising along the free lower border of the pectoralis major muscle, but this is not involved in the perfusion of the nipple using the superomedial technique.
The posterior intercostal arteries have not been shown to reliably supply blood to the nipple-areola complex.
Although the superficial thoracic artery is similar in nature to the lateral thoracic artery in the branches supplying the nipple, the vessels are transected in the process of forming a superomedial pedicle.
A 52-year-old woman is scheduled for an oncoplastic reduction mammaplasty for ductal carcinoma in situ. The patient wants to keep the native nipple-areola complex, and the plan is to design the resection to maintain the blood supply to the nipple-areola complex. Which of the following arteries is the most common dominant blood supply to the nipple-areola complex?
A) Internal thoracic
B) Musculophrenic
C) Posterior intercostal
D) Superior intercostal
E) Thoracoacromial
The correct response is Option A.
Multiple cadaver studies have examined the blood supply to the nipple-areola complex (NAC). Most studies have found that the internal thoracic artery is the dominant blood supply, anastomosing with other arteries in the anterior fat.
In a study of diagnostic MRIs ultimately given a Breast Imaging Reporting and Data System (BI-RADS) I classification, review of the blood supply to the NAC demonstrated that 53.9% of the MRIs showed medial blood supply only to the NAC, and 42.30% had multi-zone, medial with lateral blood supply. A fresh cadaver study noted the dominant blood supply branches from the internal and external thoracic arteries, and another cadaver study demonstrated that the internal thoracic arteries are the primary source of NAC perfusion. The intercostal arteries do supply the breast, but have not been shown to be dominant. The thoracoacromial artery, a branch of the axillary artery, has four major divisions: pectoral, acromial, clavicular, and deltoid. The pectoral branch also supplies the breast, and anastomoses with the intercostal arteries and lateral thoracic arteries.
A study of women who underwent nipple-sparing mastectomy with preoperative MRI demonstrated that a dominant medial blood supply occurred 71.3% of the time, and a dual blood supply occurred almost 80% of the time. NAC necrosis was less likely to occur in patients with a dual blood supply to the breasts.
Understanding common anatomy and variants allows the surgeon to plan operative approaches. Intraoperatively, surgeons can verify adequate perfusion to the NAC by using indocyanine green fluorescence angiography or fluorescein infusion.
A 30-year-old woman comes to the office for follow-up one week after undergoing bilateral reduction mammaplasty. She has no other medical history. Preoperative pregnancy test was negative. On examination, both breasts appear swollen and edematous, and thick, milky discharge is expressed from the nipples. The patient denies fever or malaise. Which of the following laboratory values is most likely to be increased?
A) C-reactive protein
B) Estrogen
C) Human chorionic gonadotropin
D) Prolactin
E) White blood cells
The correct response is Option D.
The postoperative finding of milky discharge from both breasts suggests galactorrhea, a rare but known complication after breast surgery. The etiology of galactorrhea can be multifactorial, with stimulation of prolactin secretion as the pathophysiologic basis of the symptoms. Breast manipulation, periareolar incisions, and irritation of the fourth intercostal nerve have all been implicated as origins of the afferent signals to the pituitary gland, stimulating prolactin secretion. Treatment with bromocryptine is usually undertaken.
Estrogen levels and human chorionic gonadotropin levels would be increased in pregnancy and are less likely to be increased in this recent postoperative patient, assuming a preoperative pregnancy test was negative. The symptoms of pain, edema, and bilateral breast swelling in the absence of fever and redness should alert the surgeon to a diagnosis of galactorrhea; an increased prolactin level would be diagnostic. In the absence of infection, white blood cell count and C-reactive protein levels would be normal.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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%.
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.
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.
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.
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. 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 1000 g 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.
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.
A 58-year-old man has had moderate gynecomastia with severe skin redundancy for the past eight years. A photograph is shown above. Complete physical examination and laboratory studies show no other abnormalities. Which of the following is the LEAST acceptable technique for management?
(A) Suction lipectomy with subsequent skin shrinkage
(B) Concentric circle resection
(C) Wise-pattern mastopexy
(D) Glandular resection through an areolar incision with adjunctive suction lipectomy
(E) Breast amputation and free nipple grafting
The correct response is Option C.
Gynecomastia can be classified according to three grades. Grade I gynecomastia involves visible mild breast enlargement without skin redundancy. In grade IIA gynecomastia, there is moderate breast enlargement without skin redundancy; in grade IIB gynecomastia, there is moderate breast enlargement with skin redundancy. Grade III gynecomastia is characterized by marked breast enlargement with marked skin redundancy. Although most
adolescents with gynecomastia have regression within two years (only 7.7% of affected adolescents have duration of symptoms for a longer time), regression is unlikely to be seen in this older patient, who has had severe ptosis for the past eight years.
Suction lipectomy has eliminated the need for skin resection in many gynecomastia patients, especially adolescents. Fibrous enlargement can be managed with glandular resection through an areolar incision with adjunctive suction lipectomy. However, skin resection is still recommended in older patients with grade III gynecomastia who have significant ptosis. Other procedures, such as resection of a concentric circle of skin, pedicled relocation of the nipple with skin resection, or breast amputation with free nipple grafting, may be considered. The Wise-pattern mastopexy is used to create a projecting, conical breast in women undergoing breast reduction and should not be performed in gynecomastia patients who require a breast elimination procedure.
