Breast Reduction / Gynecomastia Flashcards

Question

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

Answer 1

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.

Answer 2

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.

Answer 3

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.

Answer 4

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.

Answer 5

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.

Answer 6

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.

Answer 7

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.

Answer 8

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.

Answer 9

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.

Answer 10

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.

Answer 11

The correct response is Option C. Breast development is a complex interplay of multiple factors. Estrogen and progesterone play a significant role in breast development—not only at puberty, but also during and after pregnancy, and during and after menopause. In general, estrogen causes ductal proliferation, while progesterone causes glandular proliferations. Progesterone is similarly responsible for periductal stromal development. Estrogen increases, not decreases, cell division, and is also associated with increased, not decreased, fibrocystic changes.

Answer 12

The correct response is Option C. This patient has a fibroadenoma, the most common breast neoplasm in adolescent females. Giant fibroadenomas are typically solitary, firm, nontender, and symptoms include a rapid asymmetric breast enlargement with prominent overlying veins and occasional pressure-induced skin ulceration. These lesions are larger than 5 cm and occur at or soon after the onset of puberty. These lesions are typically treated with enucleation using reduction mammaplasty techniques for optimal symmetry with the contralateral breast. Mastectomy is not indicated, and no other adjuvant therapy is necessary. Smaller fibroadenomas may be watched conservatively, with minimal risk of malignant transformation. Surgical intervention is indicated in cases of mastodynia, neck/back pain secondary to large size, difficulty with clothing due to asymmetry, and to alleviate patient concern. Carcinoma would be unlikely in this age demographic. The differential diagnosis would additionally include cystic enlargement, breast hypertrophy, or phyllodes tumor. Juvenile breast hypertrophy may occur as unilateral or bilateral breast enlargement. The enlargement is diffuse without evidence of a discrete mass or nodularity. Juvenile breast hypertrophy typically occurs in early puberty, rarely regresses spontaneously, and is much more severe than simple breast hypertrophy. The underlying cause is attributed to estrogen stimulation at the onset of the first menses. Treatment is reduction mammaplasty. Phyllodes tumors are large, benign tumors that typically occur in the perimenopausal patient. They are histologically distinct from fibroadenomas, and transformation of a fibroadenoma to a phyllodes tumor is exceptionally rare.

Answer 13

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.

Answer 14

The correct response is Option A. Knowledge of the blood supply to the breast is important to the design of the pedicle to the nipple-areola complex. This knowledge can also be used when designing pedicles for the reconstruction of a breast after prior surgery, such as a lumpectomy. Perforating branches off of the internal thoracic artery (also called the internal mammary artery) are the predominant blood supply to the breast. The lateral thoracic and thoracoacromial arteries also contribute to the blood supply of the breast but to a lesser degree. The thoracodorsal artery and supreme thoracic artery do not contribute to the blood supply of the breast to any significant degree.

Answer 15

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.

Answer 16

The correct response is Option A. This patient has giant fibroadenoma, which is best managed by enucleation of the mass. A large breast lesion in a female adolescent may result from giant fibroadenoma, phyllodes tumor, and juvenile breast hypertrophy. Fibroadenoma is the most common breast neoplasm in adolescents; giant fibroadenoma is characterized by a lesion larger than 5 cm in diameter, presentation at or soon after puberty, and a short doubling time. Usually, the lesion is solitary, firm, and nontender and causes rapid, asymmetric enlargement of the breast, prominent overlying veins, and occasionally skin ulceration caused by pressure. Giant fibroadenomas are benign lesions that can be excised by enucleation with minimal risk of recurrence. They do not require mammaplasty, lumpectomy, mastectomy, or hormone or radiation therapy. Phyllodes tumors are large, benign tumors that occur primarily in perimenopausal patients. They are histologically distinct from giant fibroadenomas and rarely affect adolescents. They are treated with local excision or mastectomy. Juvenile breast hypertrophy is a rare but well-described disorder in young girls early in puberty. It presents as diffuse enlargement of the breast without nodules or discrete masses. It is treated by reduction mammaplasty.

Answer 17

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 juvenile breast hypertrophy. These patients also have a normal number of estrogen receptors.

Answer 18

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

Answer 19

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.

Answer 20

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.

Answer 21

The correct response is Option D. The major blood supply to the breast comes from perforating branches of the internal mammary artery, lateral branches of the posterior intercostal arteries, and branches of the axillary artery. The blood supply from the axillary artery includes the pectoral branches, the highest thoracic artery, and the lateral thoracic artery. Those vessels from the pectoral branches enter underneath the muscle before coming through it to supply the breast tissue. The vessels from the lateral thoracic artery, known as the lateral mammary branches, wrap around the lateral border of the pectoralis muscle to supply the lateral breast. The second, third, and fourth perforating branches from the internal mammary artery, known as the medial mammary arteries, enter the medial aspect of the breast. The perforating branches from the second, third, and fourth posterior intercostal arteries, known as the mammary branches, enter the breast laterally. The vascular arcades seem to be concentrated at the periphery of the breast (the cutaneoglandular plexus), and the larger vessels appear to lie not far beneath the skin, superficial to the glandular tissue. This finding has led certain authors to conclude that resection of the gland should not commence fewer than 2 to 3 cm from the chest wall; if skin flaps are elevated, they should be kept at least 2 cm thick for maximum viability. This also justifies preservation of the dermis when deepithelializing flaps to protect the subdermal plexus from injury. Perforators from the internal mammary artery and lateral thoracic artery supply the breast parenchyma. The superficial layer of the superficial fascia of the breast parenchyma does not provide vascularity.

Answer 22

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.

Answer 23

The correct response is Option A. The development of microcalcifications on mammogram images after surgery requires careful analysis. Calcifications can be grouped into three categories: malignant, indeterminate, or benign. Malignant calcifications can appear as casting (linear and branching) or pleomorphic (granular). Benign calcifications have many appearances and include popcorn-like (fibroadenoma), large rod-like (secretory), round eggshell (oil cysts), and dystrophic or coarse (fat necrosis). The development of masses, architectural distortion, and skin thickening can be seen following surgery. A complete evaluation is suggested to determine if a biopsy is necessary. Tissue biopsy is recommended for calcifications that are determined to be indeterminate or malignant.

Answer 24

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.

Answer 25

The correct response is Option A. Mammography is recommended in women older than age 35 years for detection of carcinoma. One recent study, involving women who underwent bilateral reduction mammaplasty using an inferior pedicle technique, examined findings on radiographs of the breasts six to 18 months after surgery. According to the results of this study, the most common findings were parenchymal redistribution (90.2%) and elevation of the nipple (84.9%) caused by a downward shifting of the breast tissue. Calcifications occurred in 25.6% of patients, retroareolar fibrotic banding from the transposed flap in 20.3% of patients, and oil cysts resulting from localized fat necrosis in 19.4% of patients. Thickening of the skin and areola caused by scar tissue were less common findings. Because such studies have delineated the “routine” mammography findings in patients who have undergone reduction mammaplasty, lesions can be diagnosed more easily and unnecessary biopsy procedures can be avoided.

Answer 26

Correct answer is option D. Gynecomastia, defined as benign enlargement of the male breast, can affect as many as 65% of adolescent boys. It is a condition that reflects an elevated ratio of estrogens to androgens caused by age, disease, drugs, or idiopathic factors. Gynecomastia follows a triphasic distribution seen most frequently in the neonate, in early puberty, and with advanced age as a result of normal hormonal shifts that result in a relative preponderance of estrogens over androgens. For this reason, gynecomastia in these patients is considered physiologic and rarely requires workup beyond a careful history and physical examination. The patient described comes to the office with early breast enlargement without other signs of pubertal development. Prepubertal gynecomastia is an uncommon condition, which should prompt a thorough workup for a possible pathologic cause. This is also true for patients of any age with bilateral idiopathic disease. While hormonal screening has previously been considered the first step in evaluating a patient with idiopathic gynecomastia, recent studies have suggested that these tests are rarely cost-effective. If hormone testing does suggest an occult testicular tumor, ultrasonography will be required for confirmation. Ultrasonography is therefore a preferred screening method, as it is cheaper and more accurate than hormone assays. While specific workups have historically been suggested depending on age at presentation, the arbitrary use of screening radiologic or laboratory tests has not been found to be cost-effective. The presence of a feminizing tumor in a patient with idiopathic gynecomastia is extremely rare, affecting fewer than 3% of patients. Moreover, breast hypertrophy is an uncommon sign of testicular neoplasms, occurring in 30% of Leydig cell tumors and less than 10% of beta HCG-producing carcinomas. Feminizing adrenal tumors are even rarer. Adrenal imaging is therefore not warranted. Mammogram and/or ultrasonography of the breast are reasonable choices if history and physical examination are suggestive of breast cancer. Breast cancers usually present as a hard, unilateral mass in an older patient. Karyotype testing would be warranted to rule out Klinefelter syndrome if feminizing characteristics are found on physical examination.

Answer 27

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.

Answer 28

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.

Answer 29

The correct response 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.

Answer 30

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.

Answer 31

Correct answer is option A. The number of male body contouring procedures performed in the United States has been steadily increasing over recent years, and correction of high-grade gynecomastia remains one of the most challenging procedures performed by plastic surgeons today. A grading system for gynecomastia was originally described in 1973 and later modified in 2003. Pseudogynecomastia after massive weight loss, in which the redundant breast tissue consists primarily of fat and skin, has been separately classified, and a grading system was published in 2008. Although there are minor differences between the varying classification schemas, it is generally agreed that high-grade gynecomastia, with severe ptosis and a large amount of redundant skin, may require skin resection and movement of the nipple-areola complex using either a pedicled or free nipple grafting technique. The proper position, shape, and viability of the nipple-areola complex remain the major factors in successful outcome after mastectomy and free nipple grafting in the correction of gynecomastia. Many studies have evaluated these parameters with results that are fairly consistent, although recommendations can be somewhat formulaic and cumbersome. In the simplest of schema, 100 normal male volunteers were measured to determine the appropriate anatomical parameters for nipple position and areolar diameter. It was found that patient height was the most important fixed parameter from which nipple position should be calculated. The average diameter of the nipple-areola complex in men was found to be 28 mm, and the sternal notch-to-nipple distance was found to be 20 cm. These numbers may, however, apply less in the setting of obesity or severe weight loss. One consistent finding with respect to nipple-areola configuration in men is the shape. In one study of 100 healthy male subjects performed in 2001, it was found that 91% had an oval-shaped complex with a mean ratio of horizontal-to-vertical diameter of 27:20 mm. The mean nipple-areola diameter of the 9% of patients who had a round complex was 2.3 cm. It was also found that the center of the nipple-areola complex was in the fourth intercostal space in 75% of patients and in the fifth intercostal space in 23% of patients. Unsatisfactory results after surgical correction of gynecomastia are largely secondary to improper nipple placement, with the nipple-areola complex being placed too low and close to the sternum. Moreover, to avoid a “stuck-on” appearance, use of a small oval, rather than a perfectly round shape, will result in a more natural appearance.

Answer 32

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.

Answer 33

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.

Answer 34

The correct response is Option A. The risks associated with reduction mammaplasty include local complications such as healing problems, nipple necrosis, loss of nipple sensitivity, infection, hematoma, hypertrophic scarring, fat necrosis, and asymmetry; systemic effects include deep venous thrombosis, pulmonary embolism, atelectasis, and a number of other surgical and anesthesia-related complications. The quantified risk of complications resulting from reduction mammaplasty increases with the weight of the resected specimen. These include wound-healing problems and nipple sensitivity. Some authors have recommended that normotensive anesthesia be administered throughout the procedure. While local and systemic risks are associated with elevated BMI, the degree of obesity does not demonstrate a correlation between risks and elevated body weight. The rate of hypertrophic scarring was shown to decrease with larger resections, possibly because of relief of skin tension or the presence of attenuated dermal thickness. Intraoperative hypotension, utilized to diminish blood loss during surgery, results in a higher rate of subsequent hematoma. Randomized studies documenting the risk of hematoma have shown no difference between patients with and without the use of closed suction drains.

Answer 35

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.

Answer 36

The correct response is Option C. The differential diagnosis of a large lesion in the breast of an adolescent girl includes giant fibroadenoma, phyllodes tumor, and virginal hypertrophy. Fibroadenoma is the most common breast neoplasm in the adolescent patient, and giant fibroadenoma is characterized by size greater than 5.0 cm in diameter, presentation at or soon after puberty, and short doubling time. The lesion is usually solitary, firm, and nontender and presents as a rapid asymmetric breast enlargement with prominent veins over the tumor and occasional skin ulceration due to pressure. Giant fibroadenomas are benign lesions that can be excised by enucleation with minimal risk of local recurrence. Mastectomy is not necessary for management of these lesions, and no adjuvant treatment is indicated. Phyllodes tumors are large, benign tumors that occur primarily in the perimenopausal patient. They are histologically distinct from giant fibroadenomas, and atypical changes in these tumors are rare in the adolescent. Juvenile breast hypertrophy is a rare but well-described entity in young, early pubertal girls. It presents as diffuse enlargement of the breast without any nodularity or presence of a discrete mass. Management is reduction mammaplasty.

Answer 37

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.

Answer 38

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.

Answer 39

The correct response is Option D. The contraindications to performing a vertical reduction mammaplasty are the length of the pedicle and the amount and quality of the remaining skin. Blood supply to the nipple may be compromised in a very long pedicle. It is impossible to give a numeric value to this length. Lassus recommends a transposition of no more than 9 cm. Vertical reduction mammaplasty more easily achieves consistently high €‘quality results when the method is applied to a small or moderate reduction (\< 800 g per side). Although reductions of more than 1000 g are technically difficult to achieve, they are not impossible and have been reported by some centers. With the adjunct of the L €‘shaped scar, larger amounts of skin can be resected, limiting the need for postoperative revisions. The lateral positioning of the nipples is not a contraindication to vertical reduction mammaplasty. Although Lejour reported delayed wound healing in cases with high fat content of the breast, this does not preclude the vertical method.

Answer 40

The correct response is Option A. Knowledge of normal puberty and abnormal conditions of puberty is critical for any plastic surgeon evaluating the pediatric breast. Tanner staging requires evaluation of pubic hair (males and females), genitals (males), and breasts (females). Because the patient described lacks pubic hair (Tanner I) and vaginal mucosal thickening, she has not started puberty in other areas. This excludes precocious puberty. If breasts develop before puberty has begun in other areas, it is considered benign premature thelarche and requires no intervention. Gynecomastia is a hyperplastic condition of breast tissue. The patient described does not have hyperplastic breasts. In one series, hyperplastic breast abnormalities such as gynecomastia were the most common indication for operative intervention, with an average age of operation in the late teens. McCune-Albright syndrome, also known as polyostotic fibrous dysplasia, is a condition characterized by premature puberty. Patients often begin menstruation before breast development. Patients also develop bony abnormalities, gigantism, and café-au-lait spots.

Answer 41

The correct response is Option B. The sensation to the nipple-areolar complex is derived primarily from the fourth intercostal nerve, with lesser contributions from the third and fifth intercostal nerves. The superior portion of the breast derives its sensation from the nerves of the cervical plexus; sensory innervation to the medial skin and inframammary gland is provided by the anterior cutaneous branches of the second through seventh intercostal nerves.

Answer 42

The correct response is Option B. A patient presenting with a hard, nontender lump 6 weeks after reduction mammaplasty is most likely to have fat necrosis. This is usually the result of vascular compromise to areas of the parenchyma associated with hemorrhagic necrosis. Drainage from fat liquefaction is often the first sign of infection. Cellulitis and fever may then result. Small areas of fat necrosis can be managed conservatively, and secondary revision can be performed after a period of 6 months to 1 year. If skin and fat necrosis is extensive and associated with an infection, surgical debridement and antibiotics are required. Secondary closure and grafting are required after the infection has resolved. An abscess or hematoma would be firm but likely tender. Fibroadenoma would not likely be palpable so early postoperatively. However, if the lump does not resolve within a few weeks, CT scan or ultrasonography should be considered to rule out malignancy. Seroma would most likely have a softer consistency.

Answer 43

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.

Answer 44

The correct response is Option E. The hormone most directly responsible for milk production and related breast enlargement is prolactin. Toward the end of pregnancy, high concentrations of estrogen, progesterone, and prolactin exist. After delivery, the estrogen and progesterone decrease, allowing the prolactin to promote milk production and the ensuing breast enlargement. Oxytocin is important for the milk ejection reflex but does not directly impact breast size. Luteinizing hormone impacts other aspects of female reproductive cycles but does not directly impact breastfeeding. REFERENCES: 1. Jones GE. Part I: basic principles: 1 anatomy, physiology, and aesthetics. In: Jones G, ed. Bostwick’s Plastic and Reconstructive Breast Surgery. 4th Ed. Thieme. New York; 2020. doi:10.1055/b-006-163726 2. Jatoi I, Benson J, Sbitany H. Anatomy. In: Atlas of Breast Surgery. Springer, Cham; 2020.

Answer 45

The correct response is Option E. Vertical mammaplasty is a technique that uses adjustable markings, an upper pedicle for the areola, and a central breast reduction with decreased undermining of the skin. Key features of the vertical scar reduction mammaplasty include skin excision in only one direction, which reduces scar burden, and central vertical glandular excision, which contributes to improved postoperative shape by narrowing the breast while maximizing projection as a result of suturing the medial and lateral pillars together. There is no wide periareolar skin excision; therefore, circumareolar scar quality is not compromised by excess tension. However, this method is more intuitive and inherently less precise than the inverted €‘T method. Because of the central and posterior nature of glandular resection in vertical mammaplasty, it is more difficult to determine the end point of resection. A recent study comparing vertical mammary reduction with the Wise pattern technique showed no statistical differences in the rate of hematomas and nipple numbness. Breast-feeding is possible with either technique but may require supplementation with formula. The initial shape in a vertical mammaplasty is poor; it has a flattened lower pole, and dog-ears are frequently present. This improves after three to six months, although small revisions are sometimes necessary.

Answer 46

The correct response is Option D. The findings seen in this patient are consistent with necrosis of the nipple-areola complex. This condition can be caused by direct devascularization of the breast mound, torsion, or direct pressure on the nipple and areola. Appropriate management includes immediate decompression with release of the sutures and operative exploration. Excision of the nipple-areola complex with subsequent defatting and conversion to a full-thickness skin graft is indicated for those patients who have ischemia of the breast mound identified on operative exploration. Free nipple grafting may be considered to decrease the risk for necrosis of the nipple-areola complex in women undergoing breast reduction with an estimated volume of resection of more than 1500 g on each side, a nipple transposition length of 25 cm or greater, or associated risk factors such as smoking or diabetes mellitus. Although leeches can be used to relieve venous insufficiency, this process would need to be undertaken over several days to be effective. Hyperbaric oxygen therapy increases the oxygen content of the tissue but is also a lengthy process.

Answer 47

The correct response is Option B. A large proportion of the women who seek breast reduction surgery are of child-bearing age. Because of the known advantages of breast-feeding, much attention has been directed toward the possibility of breast-feeding after reduction mammaplasty. In North American studies, 27% to 35% of postreduction patients were reported to have breast-fed in excess of two months. The most recent data indicate that 29% of women who had undergone inferior pedicle reduction mammaplasty (the procedure used on this patient) breast-fed either exclusively or with formula supplementation, 18% were unsuccessful in their attempt to breast-feed, and 53% did not attempt breast-feeding. Preservation of adequate breast tissue connected to the nipple was thought to be paramount to subsequent breast-feeding success. There was no significant difference in the mass or volume of tissue excised between the groups that breast-fed and those with an unsuccessful breast-feeding attempt. No decision about breast-feeding was attributable to perioperative complications such as wound infection or necrosis. The prevalence of breast-feeding among postreduction mammaplasty patients falls near the breast-feeding rate found in the population of child-bearing women who did not undergo breast surgery.

Answer 48

The correct response 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.

Answer 49

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.

Answer 50

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.

Answer 51

The correct response is Option B. Loss of the nipple-areola complex after reduction mammaplasty may be caused by torsion of the pedicle or by excessive tension on the closure. In the first hours after reduction mammaplasty, attempted exploration of the pedicle should be performed to release any possible tension. A blue and engorged nipple may be the first sign of impending necrosis. Other methods such as use of nitroglycerin patch may aid vasodilatation of the vessels. Conversion of the pedicle/nipple-areola complex to a free composite graft should be considered if release of the pedicle does not yield any improvement in the blood flow or if no correctable cause can be identified. Debridement and open packing of the wound is an appropriate management option when the tissues are already necrotic. Further reduction mammaplasty would release the tension on the skin flaps but would not necessarily improve the vascularity of the nipple-areola complex. Wedge resection of the central portion of the breast usually leaves unsightly scarring superior to the nipple-areola complex.

Answer 52

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.

Answer 53

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.

Answer 54

The correct response is Option E. Partial or total nipple necrosis may be one of the most devastating complications of reduction mammaplasty. The incidence of compromise of the nipple-areola complex is typically less than 5% after breast reduction. Increased BMI is a risk factor for and increased risk of both nipple necrosis and wound healing complications. Reduction mammaplasty is frequently performed on an outpatient basis. Patients are seen within a week of surgery for wound checks, but this may be too late to address a nipple with vascular compromise. If nipple ischemia is noted at the time of surgery during inset, stitches should be released and vascularity reevaluated. An objective assessment of blood flow can be aided with the use of fluorescein injection and a Woods lamp, or with newer screening modalities that are currently being evaluated for this purpose. While inset may be reattempted, the patient will likely require conversion to a free nipple graft. The nipple should be grafted to well-vascularized, deepithelialized dermis and not to ischemic fat that may be part of the compromised pedicle. If nipple ischemia is detected in the early postoperative period, and there is no hematoma or issue with external compression, the nipple should be released from its inset position. This will relieve tension on the pedicle. If the nipple does not improve, the patient is taken back to the operating room for free nipple grafting. If nipple ischemia is not identified in the early postoperative period, the patient should be treated with conservative wound care until healing is complete. Nipple reconstruction can then be undertaken in a delayed manner.

Answer 55

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.

Answer 56

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.

Answer 57

The correct response is Option E. According to several retrospective studies, prominent scarring is the most common source of patient dissatisfaction following reduction mammaplasty. "Bottoming out" of the breasts, excessive or inadequate reduction, and loss of sensation are less commonly reported as sources of patient dissatisfaction. Although patient satisfaction is generally high on follow-up evaluation, preoperative discussion of the potential long-term complications of reduction mammaplasty should be a priority for the surgeon. Long-term complications such as those mentioned above have been shown to significantly affect the patient's perception of the postoperative results.

Answer 58

The correct response is Option A. In the reduction mammaplasty technique using free nipple grafting, the nipple is totally removed from the breast and placed as a skin graft in a new, superior location. Therefore, lactation is no longer possible because the milk ducts are no longer connected to the nipple. If suction lipectomy or pedicled techniques are used, breast tissue is preserved behind the nipple and the collecting ducts are still attached to the nipple; therefore, lactation is possible. Even with these techniques, the success of breast-feeding still varies with societal influences, patient desires, amount of tissue resected, and hormonal production of engorgement and milk. In one study of 78 patients having babies after reduction, 29% breast-fed their children, 18% attempted breast-feeding and were unsuccessful, and 52% did not wish to breast-feed. In a study of 49 Brazilian women who had undergone reduction mammaplasty (breast-feeding is more common in Brazil), 58% breast-fed compared with 94% of nonoperated control subjects. The length of time that children were breast-fed was shorter in the reduction mammaplasty patients. In a third study of 30 women, 93% wished to breast-feed and were successful, although many of the babies required complementary formula feedings.

Answer 59

The correct response is Option C. Sensation to the nipple-areola complex is primarily provided by the lateral cutaneous nerve from T4. The innervation of the skin of the breast is segmental and is derived from the dermatomes associated with breast development. Knowledge of this innervation is crucial before performing breast surgery. The upper breast receives its sensation from the supraclavicular nerves that originate from the third and fourth branches of the cervical plexus. The medial and inferior aspects of the breast are innervated by small medial branches of the anterior cutaneous nerves. The lateral cutaneous branches course subcutaneously to provide sensation to the midclavicular region and contribute to the innervation of the areola.

Answer 60

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.

Answer 61

The correct response is Option D. Almost 60% of the blood flow to the breast is from the internal mammary artery. The second and third anterior perforating branches are most dominant. In a superomedial pedicle both the second and third descending branches are captured in the pedicle. In a pure medial pedicle, it is usually the third. The other branches do not constitute any significant contribution to the pedicle blood supply in a superomedial or medial reduction.

Answer 62

The correct answer is option A. Fat necrosis is a benign process occurring in approximately 1% of reduction mammaplasties. It typically presents as a firm, round or irregular, sometimes painful nodule, often developing weeks to months postoperatively. Mammographic findings of oil cysts with a thin fibrous capsule (central lucency) are characteristic. Hematomas (B) present acutely with ecchymosis and resolve earlier, while suture abscesses (C) occur along suture lines with erythema or drainage. Infiltrating ductal carcinoma (D) is less likely given the timing and imaging features. Seromas (E) are softer, fluctuant masses that arise earlier in the postoperative course. Fat necrosis is the most probable diagnosis in this clinical scenario. References: Tan PH, et al. Breast. 2006;15(3):313-318. Hogge JP, et al. Radiographics. 1995;15(6):1347-1356. Razavi SA, et al. Plast Reconstr Surg. 2021;148(4):534e-539e.

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Breast Reduction / Gynecomastia Flashcards

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