Breast Reduction / Gynecomastia Flashcards
During a reduction mammaplasty procedure, preservation of sensation in the nipple €‘areola complex is most dependent on which of the following?
(A) Amount of tissue resected
(B) Nipple-to-notch distance
(C) Pedicle location
(D) Preoperative breast volume
(E) Skin incision used
The correct response is Option C.
The most important determinant in preserving sensation in the nipple €‘areola complex is the anatomic location of glandular resection. Superior glandular pedicle techniques with tissue resections at the base of the breast are associated with higher risk of injury to the nerve supply. Lateral, inferior, and medial-based pedicles allow for better preservation of the nerve supply.
The amount of tissue resected has not been shown to have a statistically significant effect on preservation of sensation in the nipple-areola complex.
Preoperative breast volume is a factor in preoperative nipple-areola sensation (ie, the sensitivity of the nipple-areola decreases as the breast volume increases). However, preoperative breast volume, type of skin incision used, or nipple-to-notch distance have not been found to be the most important factor in preservation of nipple sensation.
Which of the following is associated with reduction mammaplasty using the vertical scar (Lejour) technique?
(A) Central vertical glandular excision
(B) Inferiorly based blood supply to the nipple
(C) Keyhole-pattern skin excision
(D) Precision in determining the endpoint of resection
(E) Wide periareolar skin excision
The correct response is Option A.
Features of the vertical (Lejour) mammaplasty include central vertical glandular excision to improve postoperative shape (by narrowing the breast while maximizing breast projection) and excision of skin in one direction only to decrease scar burden. Vertical mammaplasty is a technique of central breast reduction with undermining of the lower skin, as well as use of adjustable markings and an upper pedicle to maintain the blood supply to the areola.
Keyhole-pattern and wide periareolar resections are not features of the vertical mammaplasty; therefore, circumareolar scar quality is not compromised by excess skin tension. However, because of the central and posterior resection used with this technique, it is more difficult to determine the endpoint of resection.
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 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.
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.
A 35-year-old woman is scheduled to undergo reduction mammaplasty with removal of approximately 700 g of tissue bilaterally using an inferior pedicle technique. During preoperative marking of the patient, which of the following points should be used as a landmark to best determine the new position of the nipple?
(A) 7 cm above the inframammary fold
(B) 21 cm below the sternal notch
(C) Inframammary fold
(D) Midhumerus
(E) Xiphoid
The correct response is Option C.
In patients undergoing reduction mammaplasty, the new nipple position should be determined when the patient is in an upright position, before the procedure is performed. During preoperative marking, the inframammary fold is used as a landmark to determine the most appropriate position of the nipple on the midbreast line. This is consistent regardless of the reduction technique performed.
The midhumerus, the xiphoid, and the measured distance below the sternal notch (19 to 23 cm) are helpful but less reliable landmarks. The measurement of 7 cm above the inframammary fold is essential during surgery, when the new nipple position is being marked during closure of the incisions, but is not a reliable preoperative measurement.
A 13-year-old boy is brought for evaluation by his mother because of development of his breasts during the past 3 months. The patient is at the 50th percentile for height and weight; BMI is 22 kg/m2. Physical examination shows no abnormalities except for Grade 2 bilateral symmetric gynecomastia. Which of the following is the most appropriate next step in management?
A) Liposuction
B) Liver function studies
C) Observation and follow-up in 12 months
D) Surgical excision
E) Testicular ultrasonography
Correct answer is option C.
Three months is considered a relatively short duration for gynecomastia. Rohrich advocates waiting 12 months prior to considering surgery in the absence of other findings. Gynecomastia during puberty is common, and arbitrary use of laboratory tests in the absence of any clinical history or physical findings is not recommended. Careful history and physical examination are all that is required to identify pubertal gynecomastia. Reassurance and reassessment at 12 months are the most reasonable alternatives. If the patient still had gynecomastia that is not receding at 12 months, then surgery or liposuction would be a reasonable option. The use of other tests or biopsy is unnecessary and possibly dangerous.
Gynecomastia is an adverse effect of administration of each of the following agents EXCEPT
A) cimetidine (Tagamet)
B) digitalis (Digoxin)
C) minocycline (Minocin)
D) spironolactone (Aldactone)
E) zolpidem (Ambien)
Correct answer is option E.
Many agents have been linked to gynecomastia, such as amphetamines, cimetidine, digitalis, haloperidol, isoniazid, methyldopa, opiates, progestins, spironolactone, and tricyclic antidepressants. Associated conditions include obesity, liver disease, kidney failure, adrenal tumors, hyperthyroidism, and hypothyroidism. Gynecomastia can also be caused by increased estrogen levels (men with testicular tumors or who use androgen-based agents) or decreased estrogen levels (men with Klinefelter syndrome or who undergo orchiectomy). Zolpidem has not been shown to be a cause of gynecomastia.
Which of the following is the main disadvantage of reduction mammaplasty by liposuction alone?
(A) Dissemination of occult cancer
(B) Inability to breast-feed
(C) Inadequate correction of ptosis
(D) Increased hematoma formation
(E) Persistence of back pain
The correct response is Option C.
Liposuction alone is one of many techniques available to reduce the symptoms of macromastia. The primary advantage of this technique is the lack of scars. Several authors cite other advantages such as rapid return to work and exercise, decreased operative time, normal sensation, and full ability to breast-feed. Complications such as hematoma, seroma, and nipple necrosis are minimal compared to incisional techniques, and reductions of one to two cup sizes are reported. Symptoms of macromastia are relieved. Authors warn that this technique is not effective in young patients with dense breast tissue and little fatty tissue.
Disadvantages of this technique include difficulty assessing the amount of breast tissue removed because of the infiltration of tumescent solution, lack of pathologic examination, inadequate tissue removal in large reductions, and poor skin shrinkage. Short-term studies of postoperative mammograms show occasional benign calcifications, but longer-term studies are still needed. Dissemination of cancer is a theoretical risk but has not been reported. The incidence of occult cancer in reduction mammaplasty patients is less than 0.5%. Although nipples will rise somewhat with liposuction, the average elevation is 2 to 6 cm, and patients still have nipples which are at or below the inframammary fold (first- or second-degree ptosis).
The preferred candidate for liposuction-only reduction is described as a young patient with good skin elasticity, minimal to moderate hypertrophy, and no ptosis.
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.
A 25-year-old woman comes to the office because she has loss of sensation in the nipple-areola complexes three months after she underwent bilateral reduction mammaplasty. Which of the following intercostal nerves were most likely injured during the procedure?
(A) First and second
(B) Third and fourth
(C) Fifth and sixth
(D) Seventh and eighth
(E) Ninth and tenth
The correct response is Option B.
Recently, two separate groups have shown patterns of cutaneous innervation of the breast through detailed anatomic studies in cadavers. In general, cutaneous branches of the intercostal nerves are noted to pass through the deep fascia of the chest wall at two anatomic points: the lateral cutaneous branches at the midaxillary line and the anterior cutaneous branches beside the sternum. The breast skin is innervated by the lateral and anterior cutaneous branches of the T1 through T7 intercostal nerves. However, the contributions of the T1 and T7 intercostal nerves are small, and thus the branches of the T2 through T6 intercostal nerves are likely more important. There is no contribution by the T8 through T12 intercostal nerves to innervation of the breast skin.
Innervation to the nipple-areola complex is supplied by the anterior and lateral cutaneous branches of the T3 through T5 intercostal nerves. While all of these nerves supply branches, the T4 intercostal nerve is the most consistent in its contribution to innervation to the nipple-areola complex. Also, the cutaneous area of sensation of the nipple-areola complex, supplied by the T4 intercostal nerve branches, is larger than that supplied by the T3 or T5 intercostal nerve branches. Therefore, the T4 intercostal nerve is the primary nerve for cutaneous innervation to the nipple-areola complex, but it is not the sole supplier of this innervation.
An otherwise healthy 25-year-old man comes to the office because of a 10-year history of bilateral gynecomastia. Physical examination shows breast enlargement with skin redundancy and palpable glandular and fatty tissue. Which of the following is the most appropriate next step in management?
A) Determination of 17-ketosteroid level in urine
B) Mammography
C) Referral to an endocrinologist
D) Surgical excision
E) Testicular ultrasound
Correct answer is option D.
The most appropriate next step for the patient described, who is young with a long history of bilateral gynecomastia since puberty, is surgical excision. The onset of gynecomastia correlates with transient elevations of plasma estradiols prior to the completion of puberty so that the androgen-to-estrogen ratio is altered. Suction lipectomy can also be used as surgical treatment for gynecomastia. Most cases of gynecomastia present at puberty, with an incidence as high as 65% in boys 14 to 15 years of age. The condition disappears during the late teens, with only 7.7% remaining at age 17 years. The incidence rises again with progressive age. The condition is often a normal finding, even though it may be associated with a more serious disease in occasional cases. In certain cases, systemic causes — such as liver disease, lung carcinoma, testicular carcinoma, adrenal tumors, thyroid disease, testosterone imbalance, and Klinefelter syndrome — or drugs like marijuana, should be considered. For instance, a prepubescent boy presenting with gynecomastia would cause concern. Another example would be if an adult man presented with a 6-month history of unilateral gynecomastia. A work-up including liver function test, urine studies, testicular examination, endocrinology evaluation, and possibly mammography should be done if there is a possibility of cancer (ie, patients with Klinefelter syndrome).
A 20-year-old man is scheduled for gynecomastia reduction by the use of ultrasound-assisted lipoplasty. In planning this procedure, which of the following liposuction techniques has the highest risk of thermal injury to the skin?
A) Dry
B) Wet
C) Superwet
D) Tumescent
Correct answer is option A.
Ultrasound-assisted liposuction in a dry environment increases the risk of thermal injury and overlying skin necrosis. The introduction of subcutaneous fluid in the wet, superwet, and tumescent techniques helps cool the probe and decreases the risk of injury. Additionally, avoidance of end hits, strict continuous movement of the probe, continuous cold saline irrigation, and use of a probe sheath and a wet towel as a skin guard also protect against thermal injury when ultrasound energy is delivered to the tissues.
A 57-year-old man comes to the office for consultation regarding enlargement of the breasts. Physical examination shows bilateral large, ptotic, female-appearing breasts with firm, tender, glandular-like tissue deep to each nipple. Laboratory studies show increased beta-human chorionic gonadotropin level. Which of the following studies is the most appropriate next step in establishing the diagnosis?
A) Biopsy of the breast
B) CT scan of the abdomen
C) Mammography
D) MRI of the brain
E) Ultrasonography of the testes
The correct answer is option E.
In adults with gynecomastia, thorough medical evaluation is required. History and physical examination should identify new medications, drug and alcohol abuse, and endocrine, hepatic, or pulmonary disease. Laboratory studies should measure electrolytes, blood urea nitrogen, creatinine, testosterone (total and free), estradiol, follicle-stimulating hormone, luteinizing hormone, beta-human chorionic gonadotropin (_-hCG), prolactin, liver function, and thyroid function. Radiography should also be performed. These tests are intended to rule out germ cell tumors, primary hypogonadism, hyperthyroidism, androgen resistance, pituitary tumors, secondary hypogonadism, and lung cancer. Mammography is not routinely used unless there is a finding on physical examination that shows possible presence of breast cancer; there is no known association between gynecomastia and breast cancer (except in Klinefelter syndrome). Imaging of the brain is not routinely ordered unless there is some other finding suggestive of a brain tumor. If the _-hCG concentration is increased, ultrasonography of the testes is indicated to rule out germ cell and non–germ cell tumors. CT scan of the abdomen should be ordered only if ultrasonography of the testes is negative.
A 13-year-old boy with gynecomastia desires corrective surgery. An initial preoperative evaluation of this patient should include examination of which of the following?
A) Eyes
B) Regional Lymph Nodes
C) Pectoralis muscle
D) Abdomen
E) Genitalia
Correct answer is option E.
The genitalia should be examined in this 13-year-old boy with gynecomastia. Although most adolescent boys with breast development do not exhibit other signs of feminization caused by hormonal excess or other genetic problems, examination of the genitalia could reveal an underlying cause of the gynecomastia. Testicular tumors are typically palpable on physical examination, and some adolescent boys will have nonpalpable and/or undescended testes. In patients with these findings, genetic and/or endocrine evaluation is required before any operative procedures are performed. Visual fields may be altered in a patient who has a pituitary tumor, and patients with adrenal tumors may have palpable abdominal masses. Examination of these sites should be performed secondarily to examination of the genitalia. Thyroid abnormalities are not associated with gynecomastia. The pectoralis muscle may be partially absent in patients with Poland syndrome but not in patients with gynecomastia.
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.
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 16-year-old girl has had rapid, asymmetric enlargement of the left breast over the past year. On physical examination, an 18-cm mass can be palpated; there is ptosis and stretching of the nipple-areola complex. The veins are prominent and dilated, and there is ulceration of the skin superolateral to the nipple. Mammography shows a dense, circumscribed, homogeneous mass that encompasses the entire breast.
Which of the following is the most appropriate management?
(A) Hormone therapy
(B) Enucleation
(C) Subcutaneous mastectomy
(D) Simple mastectomy
(E) Reduction mammaplasty
The correct response is Option B.
This 16-year-old girl has fibroadenoma, which is the most common neoplasm of the breast in adolescents. Giant fibroadenomas are typically solitary, firm, nontender, benign lesions that develop at or soon after the onset of puberty. They are larger than 5 cm in diameter and double in size within a short time. Rapid enlargement of one breast is characteristic. Prominent veins are noted over the arc of the tumor; some patients develop skin ulcerations because of the pressure caused by the fibroadenoma. Enucleation is curative, and the risk for local recurrence is minimal.
Hormone therapy would only stimulate growth of the glands within the breast.
Mastectomy is excessive and unnecessary in patients with giant fibroadenoma.
Reduction mammaplasty is indicated for management of juvenile breast hypertrophy, which is characterized by diffuse enlargement of the breast without a palpable mass or nodes.
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%.
A 63-year-old man comes to the office for consultation regarding correction of large breasts. Detailed history and physical examination show no cause of his condition. The breasts are a size C cup with ptosis and excessive skin. The nipples are 5 cm in diameter. Mastectomy and free nipple grafts are planned. The desired new size and shape of each areola are closest to which of the following?
A) 1 cm, round
B) 2 cm, round
C) 2 cm, oval
D) 3 cm, oval
E) 4 cm, round
Correct answer is option D.
Larger forms of gynecomastia with significant ptosis present a challenge to plastic surgeons with respect to the size, shape, and position of the nipple on the chest wall. In addition, the nipple-areola complex may need to be reconstructed due to loss from cancer or trauma.
Two recent studies investigated the anatomical parameters of the nipple-areola complex in men. These studies demonstrated the following characteristics. More than 90% of the male subjects had nipples that were oval in configuration. The average areolar diameter in one study was 2.8 cm. The average areolar diameter in the other study was 2.7 cm. Furthermore, in men, the position of the nipple on the chest wall is typically 20 cm from the sternal notch and 18 cm from the midclavicular line. The ideal nipple-to-nipple distance in men is 21 cm.
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 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.
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 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.
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.
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 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.
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 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.
Which of the following is the estimated incidence of detection of occult breast cancer during reduction mammaplasty?
(A) 0.002%
(B) 0.02%
(C) 0.2%
(D) 2%
(E) 20%
The correct response is Option C.
The average risk of occult breast cancer in patients undergoing breast reduction has been estimated to be 0.27% (0.11%, 0.75%, 0.71%, 0.05%, 0.06%, 0.16%, and 0.09% in seven journal articles published between 1997 and 2006). Cancer is often found at the in situ or early stages. Definitive therapy depends on size, pathology, location, and status of margins. Consultation with an oncologist and further pathologic analysis are generally necessary.
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.
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 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.
On the basis of evaluation of cutaneous light-pressure thresholds of the breast with Semmes-Weinstein monofilaments, which of the following areas of the breast is most sensitive?
(A) Areola
(B) Inferior quadrants
(C) Nipple
(D) Superior quadrants
The correct response is Option D.
Based on the evaluation of cutaneous light-pressure thresholds with the Semmes-Weinstein monofilaments, there are marked differences in sensory perception between the skin of the breast, the areola, and the nipple. Irrespective of breast size, the skin in the superior quadrant is the most sensitive part of the breast, the areola is less sensitive, and the nipple is the least sensitive part to light pressure. The fact that the nipple is the least sensitive area in the female breast is thought to allow the mother to nurse without discomfort. Vibration is most sensitive in the areola.
Larger breasts are significantly less sensitive than smaller breasts in all anatomic areas, and there is a significant decrease of sensibility with increasing breast ptosis. Sensitivity tends to decrease with age.
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.
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 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.
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.
