Mammaplasty: Augmentation/Mastopexy Flashcards
A 36-year-old woman comes to the office for consultation regarding augmentation mammaplasty. She wears a size 34B brassiere and wants the size increased to a full C cup. Height is 5 ft 6 in (168 cm) and weight is 126 lb (57 kg). She feels her breasts are reasonable in appearance but has been encouraged by her husband, from whom she is separated, to seek enhancement. The risks of the surgery, including loss of nipple-areola sensation and the need for prosthesis maintenance over time, are discussed. She opts to proceed with surgery, and 375-mL saline breast prostheses are placed subpectorally through inframammary fold incisions. Which of the following is most likely to cause patient dissatisfaction after the procedure?
A ) Continued separation from her husband
B ) Deflation of the breast prostheses
C ) Hypertrophy of the breast scars
D ) Inability to breast-feed
E ) Inadequate breast size
The correct response is Option A.
Thorough patient evaluation before surgery, including screening, discussion of risks and complications, and the need for realistic expectations, is necessary to optimize patient satisfaction after surgery. This is especially true of aesthetic surgery.
Despite these efforts, patient dissatisfaction occurs and can be extremely difficult to manage. Patient dissatisfaction is usually associated with failures in communication and patient selection criteria. Determining which patients are unsuitable for operation is a skill acquired with experience. General guidelines include patients who (1) have unrealistic expectations, (2) are excessively demanding, (3) have dissatisfaction with a previous surgical procedure, (4) are psychologically unstable, and (5) have a minimal deformity.
In the scenario described, the patient has an unrealistic expectation that the surgery might save her marriage. Because of her motivation for surgery, she is unlikely to be happy, despite a very good result, unless the expectation of reconciliation has been fulfilled.
The other options are possible causes of postoperative dissatisfaction; however, preoperative counseling and education of the potential complications allow for enhanced acceptance if they do occur.
A 47-year-old woman is referred by her primary care physician to evaluate a suspected intracapsular rupture of her prosthesis on the left identified during routine mammography. She underwent primary augmentation mammaplasty with subglandular placement of single-lumen silicone breast prostheses in 1990. Physical examination shows a smaller breast on the left. An MRI is requested. Which of the following findings on MRI is most likely to confirm the diagnosis?
A ) Double wall sign
B ) Linguine sign
C ) Multiple echogenic lines
D ) Reverse double-lumen sign
E ) Snowstorm sign
The correct response is Option B.
MRI, mammography, ultrasonography, and CT scanning have all been used to diagnose silicone breast prosthesis rupture.
Although each modality has specific strengths and weaknesses that may make a particular modality the study of choice for an individual patient, MRI of silicone breast prostheses reports the highest sensitivity and specificity for detection of silicone prosthesis rupture.
Of the options listed, only the linguine sign is consistent with intracapsular silicone prosthesis rupture and represents the prosthesis shell floating in free silicone gel.
The double wall sign, also known as Rigler sign, is a radiographic sign of pneumoperitoneum.
Snowstorm sign and echogenic lines may be seen on ultrasound examination.
Water suppression or a reverse double-lumen sign would not be expected findings in a single-lumen device but may have a role in double-lumen devices.
A 26-year-old woman comes to the office for consultation regarding right mammary hypoplasia and a superiorly displaced nipple-areola complex. Examination shows a depressed right chest wall. The pectoralis major muscle is anatomically normal. Which of the following is the most likely diagnosis?
A ) Anterior thoracic hypoplasia
B ) Pectus carinatum
C ) Pectus excavatum
D ) Poland syndrome
E ) Sternal cleft
The correct response is Option A.
The most likely diagnosis in this patient is anterior thoracic hypoplasia. Anterior thoracic hypoplasia is a syndrome composed of an anterior chest wall depression resulting from posteriorly displaced ribs, hypoplasia of the ipsilateral breast, and a superiorly displaced nipple-areola complex. The sternum is in normal position, and the pectoralis major muscle is normal.
Pectus excavatum is the most common congenital chest wall abnormality in which the ribs and sternum form abnormally, resulting in a concave anterior chest wall. Typically, the lower third of the sternum is involved. In the most severe form, pectus excavatum can present with the sternum adjacent to the vertebral bodies associated with cardiopulmonary abnormalities. In contrast, pectus carinatum is a chest wall deformity in which the sternum and ribs are forced anteriorly, creating the appearance of a pigeon’s chest. Pectus excavatum and carinatum have sternal involvement, but they do not involve changes in the development of the breast.
Poland syndrome is a congenital anomaly characterized by a number of unilateral findings. The classic features of Poland syndrome include absence of the sternal head of the pectoralis major, hypoplasia and/or aplasia of the breast or nipple, deficiency of subcutaneous fat and axillary hair, abnormalities of the rib cage, and upper extremity anomalies. In its simplest form, Poland syndrome may present with only mild hypoplasia of the breast and lateral displacement of the nipple. Complex presentations of Poland syndrome include hypoplasia or aplasia of the chest wall musculature (serratus, external oblique, pectoralis minor, and latissimus dorsi muscles) or total absence of the anterolateral ribs with herniation of the lung.
Sternal cleft is a rare congenital defect of the anterior chest wall resulting from a failure of midline fusion of the sternum. Depending on the degree of clefting, there are complete and incomplete forms. The sternal cleft is clinically significant because of the potential for the lack of protection to the heart and great vessels. Sternal clefts are not associated with aplasia or hypoplasia of the breast.
A 20-year-old woman comes to the office for consultation regarding augmentation mammaplasty. Height is 5 ft 4 in (163 cm) and weight is 120 lb (54 kg). Physical examination shows mammary hypoplasia. She currently wears a size 34B brassiere and would like to wear a size C brassiere. Which of the following is the most appropriate option for breast enhancement?
A ) Autologous fat transfer
B ) Breast Enhancement and Shaping System (BRAVA)
C ) Saline prostheses
D ) Smooth gel prostheses
E ) Textured gel prostheses
The correct response is Option C.
Augmentation mammaplasty is one of the most common plastic surgery operations. During the moratorium on silicone gel prostheses between 1992 and 2006, the saline breast prosthesis became the prosthesis of choice. When a saline prosthesis ruptures, it decreases in size as the saline leaks out and is absorbed by the body. The deflated side is usually noticeable to the patient and can be compared to the nondeflated side for further distinction. The saline may leak out slowly, taking a week or longer to be noticeable.
When the Food and Drug Administration lifted the moratorium on silicone gel prostheses, it stipulated that women must be 22 years of age to use the gel prosthesis. Therefore, for the patient described, the only option is saline.
Saline prostheses are firm to the touch, and on very thin patients the normal rippling can be palpated through the skin, especially noticeable along the lower, outer pole where there is no pectoral muscle coverage.
Autologous fat transfer is reported in the literature but would be difficult to do on this very thin patient. Harvesting enough fat to achieve the goal of a size C brassiere would be difficult.
The BRAVA system can increase breast size but only minimally, so it is unlikely that this would give the patient enough volume for her goal of a size C brassiere.
The deflation rate of saline prostheses is debated in the literature, related to prosthesis type (textured versus smooth), fill volumes, and physician technique. It is agreed that the expected lifespan of the saline prosthesis is 10 years.
A 42-year-old woman with Grade 3 ptosis of the breasts is scheduled to undergo augmentation mammaplasty and mastopexy. Which of the following operative decisions is most likely to have an adverse effect on the outcome of the procedure?
A ) Augmentation mammaplasty and use of vertical mastopexy technique
B ) Augmentation mammaplasty and use of a Wise-pattern mastopexy technique
C ) Mastopexy and placement of 450-mL saline prostheses in a dual-plane pocket
D ) Mastopexy and placement of 200-mL silicone prostheses in a subpectoral pocket
E ) Performance of the operation in two stages
The correct response is Option C.
Augmentation mammaplasty and mastopexy is a complex procedure that can increase the risks and difficulties beyond those of each one performed independently. A mastopexy is designed to raise the nipple-areola complex and reshape the breast by resecting skin and tightening the parenchyma. In direct opposition to this shaping, an augmentation enlarges the volume of the breast and expands the skin envelope. Further, mastopexy techniques involve elevation of flaps that require adequate vascularity, while prosthesis placement devascularizes the breast and puts direct pressure on the remaining circulation.
The larger the prosthesis, the greater the adverse effect on vascularity. This can lead to early problems with nipple-areola complex loss, skin flap loss, prosthesis infection and exposure, and resultant deformities.
Larger prostheses are also associated with long-term complications of soft-tissue attenuation. This results in tissue thinning, stretching, atrophy, rippling, and recurrent ptosis. Despite conflicting studies, prosthesis size of 350 mL is considered the crossover to large prostheses.
Despite these risks, most patients want to have both operations performed simultaneously. If these patients are accepted, it is the surgeon €™s responsibility to minimize complications.
Some surgeons prefer to perform augmentation and mastopexy in two separate operations to control the result and reduce the complication rate.
Placement of 200-mL silicone prostheses in a subpectoral pocket is less likely to cause problems because of their modest size.
Vertical mastopexy and Wise-pattern techniques are both acceptable procedures that can be applied to patients with Grade 3 ptosis.
Which of the following innervates the nipple-areola complex?
A ) Intercostal
B ) Lateral pectoral
C ) Long thoracic
D ) Supraclavicular
E ) Thoracodorsal
The classic teaching ascribes nipple innervation to the fourth intercostal nerve. More recent anatomical studies have confirmed that the nipple is innervated by a rich subdermal plexus of nerves that provide both tactile and pressure sensation. This plexus receives innervation from the lateral and anterior cutaneous branches of the second to fifth intercostal nerves. This plexus explains why the nipple can retain sensation despite extensive surgical procedures.
The lateral pectoral innervates the pectoralis major muscle. The long thoracic innervates the serratus anterior muscle. The supraclavicular innervates the skin of the upper breast. The thoracodorsal innervates the latissimus dorsi muscle.
Which of the following sequelae is more likely to result from the use of textured silicone gel prostheses rather than smooth silicone gel prostheses?
A ) Capsular contracture
B ) Hematoma
C ) Malposition
D ) Rippling
E ) Rupture
The correct response is Option D.
The use of textured prostheses is associated with a significant rate of rippling when compared with smooth prostheses. One study reported over a two-fold increase. Visible rippling can be minimized with subpectoral implantation as well as by limiting the use of these prostheses to patients with more native breast tissue. Rippling is more pronounced with saline-filled prostheses.
Rippling occurs when the breast skin and soft tissue are thin. This rippling will worsen with time because of the skin stretching and thinning. The key to treatment is to thicken the breast skin or change the prosthesis characteristics. Overinflation of saline prostheses is thought to minimize rippling; however, one recent study did not show any difference in the incidence of rippling in underfilled saline prostheses. Surgical treatment for rippling is usually incomplete. Dermal grafts have been used with some success to thicken the rippled breast skin. Changing a saline prosthesis to a cohesive silicone gel prosthesis will also improve rippling. Various flaps can also be used to reinforce the thinned breast skin.
Textured surface prostheses are superior to smooth prostheses in decreasing capsular contracture. However, this advantage is minimal when using saline prostheses in a subpectoral pocket.
The incidence of hematoma formation is similar for both types of prostheses.
Rupture rates for textured gel and saline gel are similar; however, textured saline prostheses have a higher rate of deflation than smooth saline prostheses.
Malposition rates are not higher with the use of textured prostheses.
A 40-year-old nulliparous woman comes to the office because she is dissatisfied with the “saggy” appearance of her breasts following a 120-lb (54-kg) weight loss. Physical examination shows bilateral Grade 3 ptosis. Which of the following additional findings on examination of the breasts is most likely in this patient?
A ) Flatness of the upper pole
B ) High inframammary fold
C ) Lack of axillary fat roll
D ) Lack of excess skin
E ) Laterally displaced areolas
The correct response is Option A.
The types of breast deformities seen following massive weight loss are relatively new. To adequately manage these patients and assess outcomes, it is important to understand the defect. Classification systems exist for breast ptosis for other causes; however, these are based mainly on nipple position. Breast deformities after massive weight loss vary significantly. Patients typically present with severe breast ptosis (Grade III), medialization of the nipple-areola complex, lateralization of the breast mound, and extension to a lateral axillary fat roll, which often extends well into the back. The inframammary fold is often in a lower position because of deflation of the entire skin and connective tissue envelope. Beyond the typical breast changes of glandular tissue loss and ptosis, there tends to be more asymmetrical volume loss in the massive weight loss breast, and there is more of a deflated and flat appearance of the breast (particularly a flat upper pole). Skin laxity is very apparent, and the degree of excess skin can be significant.
A 24-year-old woman is undergoing endoscopic transaxillary augmentation mammaplasty. Which of the following is most appropriate to preserve sensation in the medial aspect of the upper extremity?
A ) Avoiding dissection into the axillary fat
B ) Blunt dissection near the clavicle
C ) Identification of the sensory nerves within the axilla
D ) Positioning of the prosthesis subpectorally
E ) Preservation of the lateral pectoral nerve
The correct response is Option A.
During transaxillary augmentation mammaplasty, prevention of sensory changes to the medial aspect of the upper extremity requires a subdermal dissection and avoids dissection into the axillary fat. Branches of the intercostobrachial and medial brachial cutaneous nerves provide sensory innervation to the medial upper extremity. Both nerves course superficially through the axillary fat posterior to the lateral border of the pectoralis major muscle. Dissection within the axillary fat risks injury to these nerves with subsequent anesthesia or paresthesia of the inner arm.
Identification of the nerves within the axilla requires dissection into axillary fat and risks injury to the sensory nerves. Sensory innervation to the medial aspect of the upper extremity is not affected by the positioning of the prosthesis (subpectoral versus subglandular) or dissection near the clavicle. The lateral pectoral nerve provides motor innervation to the lower third of the pectoralis major muscle.
A 35-year-old woman comes to the office for consultation regarding augmentation mammaplasty. A preoperative mammogram is most indicated if the patient’s history includes which of the following?
A ) A grandmother diagnosed with breast cancer at age 73 years
B ) A mother diagnosed with breast cancer at age 45 years
C ) Personal history of breast cysts
D ) Personal history of fibroadenoma
E ) A sister diagnosed with ovarian cancer
The correct response is Option B.
Among the risk factors for breast cancer, family history is the most significant. It can be divided into two broad categories: familial breast cancer, which most likely results from changes in multiple low penetrance genes coupled with environmental influences, and hereditary breast cancer, which results in high penetrance mutation in a single gene.
Familial breast cancer is relatively common and conveys a modest elevation in risk compared with genetic breast cancer, which is rare but associated with high risk.
A family history of breast cancer has been demonstrated to increase the risk of breast cancer in multiple studies. Breast cancer in a first-degree relative increases the risk of breast cancer, and that risk decreases as the age of the affected relative increases (ie, it is a 2.3 relative risk factor if the affected relative is under 50 years of age; it is 1.8 if she is over 50). Individuals whose first-degree relatives have bilateral breast cancer have an increased risk of 5.5 times the normal population.
A 48-year-old woman comes to the office because she is dissatisfied with the “sagging” appearance of her breasts. Physical examination shows the location of the nipples 1 cm above the inframammary fold bilaterally. The majority of breast tissue is below the fold. Which of the following is the most likely diagnosis?
A ) Grade 1 ptosis
B ) Grade 2 ptosis
C ) Grade 3 ptosis
D ) Pseudoptosis
The correct response is Option D.
Regnault defined the degree of ptosis by evaluating the relationship of the nipple to the inframammary fold.
In pseudoptosis, the nipple is above or at the level of the inframammary fold, with the majority of the breast tissue below. This gives the impression of ptosis.
In Grade 1, or mild ptosis, the nipple is within 1 cm of the level of the inframammary fold and above the lower contour of the breast and skin envelopes. In Grade 2, or moderate ptosis, the nipple is 1 to 3 cm below the inframammary fold but above the lower contour of the breast and skin envelopes. In Grade 3, or severe ptosis, the nipple is more than 3 cm below the inframammary fold and below the lower contour of the breast and skin envelopes.
A 45-year-old woman comes to the office for consultation regarding augmentation mammaplasty. She wears a size 32B brassiere; height is 5 ft 3 in (160 cm), and weight is 130 lb (59 kg). Subglandular placement of saline prostheses is planned. Which of the following is the primary advantage of using saline rather than silicone prostheses in this patient? A)Easier detection of rupture BLess capsular formation C)Less wrinkling D)Lighter prosthesis E)Lower risk of leakage
The correct response is Option A.
Although both silicone and saline prostheses rupture at a similar rate, a saline rupture is more easily detectable because the saline is resorbed in the body. The deflated breast will be smaller in volume. Subtle changes, such as decreased upper pole fullness or increased softness, may be the only clues to silicone rupture on physical examination. Ultrasonography or MRI may be needed to confirm the diagnosis.
Saline prostheses are firmer than silicone; they are more likely to be palpable than silicone prostheses as well. Neither prosthesis has been associated with systemic immune syndromes, and both prostheses produce capsular contracture, wrinkling, and leakage.
A 28-year-old woman comes for follow-up evaluation 2 weeks after undergoing bilateral augmentation mammaplasty with subpectoral placement of 325-mL, round, smooth saline prostheses. She is now concerned that both prostheses appear “too high.” Physical examination shows fullness in the upper quadrants of both breasts. Which of the following interventions is most appropriate?
A)Administration of oral zafirlukast
B)Application of a circumferential breast band
C)Injection of corticosteroid into the inframammary crease
D)Open capsulotomy
E)Percutaneous release of the inframammary crease
The correct response is Option B.
The most appropriate recommendation is breast band application. Breast shape following augmentation mammaplasty undergoes dynamic changes. The skin envelope and pectoralis muscle stretch under the expansion pressure of the prosthesis. The skin of the lower pole will stretch, allowing the prostheses to migrate inferiorly. Breast massage and a circumferential elastic breast band applied around the superior breast encourage this migration.
Zafirlukast is a leukotriene-antagonist that is used for the treatment of asthma. Preliminary studies suggest improvement in capsule contractures. This drug is associated with potential life-threatening liver complications as well as neuropsychiatric events. Because administration in the scenario described would constitute an off-label use of the drug, extensive discussion with the patient would be required prior to use.
In the past, steroid was injected into the saline compartment of a double-lumen prosthesis in an attempt to decrease the incidence of capsule contraction. This delivery system was uncontrolled and many prostheses migrated beyond the normal limits of the inframammary crease. Postoperative steroid injection has been used with some success for the prevention of recurrent capsule contracture following capsulectomy.
If residual inferior pectoralis muscle fibers are left intact along the rib or capsule contracture develops, open capsulotomy may be required; however, conservative treatment is indicated at this early postoperative period.
Percutaneous release would expose the patient to unnecessary complications of prosthesis injury, bleeding, and inframammary crease malposition.
A 40-year-old woman comes to the office because of firmness of the right breast. Twenty years ago, she underwent augmentation mammaplasty with smooth silicone prostheses placed in subglandular pockets. Which of the following is the most appropriate management? A)Injection of corticosteroids B)Treatment with zafirlukast (Accolate) C)Closed capsulotomy D)Open capsulotomy E)Total capsulectomy
The correct response is Option E.
In the patient described with a capsular contracture, the most appropriate option is open capsulectomy. As opposed to open capsulotomy, open capsulectomy removes the entire capsule. Leaving the capsule behind in open capsulotomy can contribute to late seromas. Scar tissue left behind during an open capsulotomy may also prevent the prosthesis and breast from obtaining a natural shape.
Closed capsulotomy is no longer advised for breast prostheses because of the risk of rupturing the prosthesis during the procedure. Open capsulotomy and open capsulectomy with replacement of the prosthesis in the subglandular plane will continue to be associated with higher capsular contracture rates than submuscular or dual-plane placement. These are options for the patient as long as she understands the trade-offs of keeping the prosthesis in this plane.
Zafirlukast (Accolate) is a leukotriene receptor antagonist that is used as a bronchodilator in the management of asthma. The evidence supporting its use in capsular contracture is anecdotal. It is not approved by the US Food and Drug Administration (FDA) for use in capsular contracture; therefore, its use in the scenario described would be considered an ?off-label? indication. As such, zafirlukast cannot be recommended for the routine treatment of capsular contracture.
A 24-year-old woman comes to the office 8 months after undergoing a circumareolar mastopexy/augmentation. She is concerned because her areolas are now asymmetric. They were symmetric preoperatively. Physical examination shows that the right areola diameter is 7 cm and the left areola diameter is 4 cm. The most likely cause of this asymmetry is a failure of which of the following? A)Breast pillar approximation B)Periareolar de-epithelialization C)Prosthesis pocket D)Purse-string suture E)Skin envelope tailor tacking
The correct response is Option D.
The most likely cause of nipple-areola asymmetry in the patient described is failure in the purse-string suture. Periareolar mastopexy/augmentation has been plagued with inconsistent control of the nipple-areola complex diameter. This mastopexy technique creates concentric resection of periareolar epithelium to elevate the nipple-areola complex and reduce the skin envelope. The etiology of this areola-spreading is the tension of the closure intrinsic to the technique. Use of a permanent suture for the purse-string helps limit the postoperative spreading of the areolar diameter. Introduction of the interlocking polytetrafluoroethylene (GORE-TEX) suture has allowed improved control of areolar shape and diameter. If one of the purse-string sutures breaks or pulls through its dermal attachments, that areola will be subject to the forces of tension and expand in diameter. In the patient described, operative correction involves either replacing the purse-string on the widened side or removing the purse-string on the smaller diameter areola.
Periareolar de-epithelialization is the cause of the tension and is an essential part of the procedure. In patients who are significantly asymmetric, tension of the areolas will also be asymmetric; however, a permanent purse-string suture is crucial in these cases.
Prosthesis pocket and parenchyma shaping sutures will not have the impact on areolar diameter that is described in this scenario.
Envelope tailor tacking relates to final adjustments in periareolar de-epithelialization.
