Mastopexy Specific Flashcards
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.
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 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 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.
A 50-year-old woman comes to the office for consultation about improving the appearance of her “saggy” breasts. She has lost 100 lb (45 kg) during the past 18 months by diet. Photographs are shown. Physical examination shows breast deflation and marked ptosis. A Wise pattern mastopexy with augmentation mammaplasty is planned. Which of the following arteries is most likely to provide circulation to the breast gland and nipple during submuscular augmentation in this patient?
A)Intercostal
B)Pectoral
C)Superior epigastric
D)Thoracoacromial
E)Thoracodorsal
The correct response is Option D.
The thoracoacromial artery and vein travel just deep to the pectoralis major muscle, supplying circulation to the overlying breast tissue and skin. Subglandular augmentation mammaplasty disrupts the connection between the thoracoacromial vessels and the overlying breast. This leads to a higher risk of wound-healing complications when placing the prosthesis in the subglandular plane. The submuscular plane of dissection maintains the connection between the thoracoacromial vessel and overlying breast and skin, allowing better potential healing.
Intercostal arteries are multiple and are not completely disconnected with either subglandular or subpectoral augmentation mammaplasty.
The superior epigastric artery provides circulation to the rectus abdominis muscle and abdomen. This artery would be injured with the mastopexy procedure.
The thoracodorsal artery supplies the latissimus dorsi muscle and not the chest.
A 45-year-old woman comes for evaluation 1 year after undergoing vertical mastopexy without placement of prostheses because she thinks her breasts have started to sag. An increase in which of the following breast dimensions has most likely occurred since the patient’s last visit?
A) Breast base diameter
B) Nipple to inframammary crease
C) Nipple-areola diameter
D) Suprasternal notch to inframammary crease
E) Suprasternal notch to nipple
The correct response is Option B.
The nipple-to-inframammary crease dimension is most likely to increase over time. This leads to pseudoptosis (bottoming out) and the appearance of a sagging breast. Pseudoptosis occurs when the breast gland migrates lower than the inframammary crease while the nipple stays in normal position. It is essential that patients be informed that their breasts will eventually sag following mastopexy. Procedures to prevent this from occurring include the use of permanent mesh encircling the breast mound. Mastopexy and reduction mammaplasty share similar operative strategies as well as complications. All techniques suffer bottoming out to different degrees.
Breast base diameter will change very little over time as long as the breast volume remains constant; eg, weight gain can increase breast volume.
An increase in the nipple-areola diameter is unlikely with vertical mastopexy; however, increased areola diameter is associated with periareolar mastopexy. To minimize this complication, a permanent purse-string suture is recommended. Suprasternal notch-to-inframammary crease distance changes very little in comparison with the nipple-to-inframammary crease distance.
The suprasternal notch-to-nipple distance changes very little postoperatively. When a prosthesis is used during mastopexy, this distance will increase; however, the nipple-to-inframammary crease will usually increase to a greater extent.
A 33-year-old woman comes to the office for consultation because she is dissatisfied with the “sagging” appearance of her breasts. Examination shows grade II ptosis and loss of fullness in the upper pole. A vertical mastopexy is planned. The most common medial innervation to the nipple-areola complex is the anterior cutaneous branches of which of the following intercostal nerves?
A) Second and third
B) Third and fourth
C) Fourth and fifth
D) Fifth and sixth
E) Sixth and seventh
The correct response is Option B.
The most common medial innervation of the nipple-areola complex is mainly 57% from the anterior cutaneous branches of the third and fourth intercostal nerves. The third intercostal nerve accounts for 21.4%. They always reach the areolar edge between 8 and 11 o’clock on the left and 1 and 4 o’clock on the right. The nerve innervation to the nipple-areola complex is important in planning different incisions around the areola in both reduction mammaplasty and mastopexy.
A 23-year-old woman comes to the office for consultation regarding surgical correction of a tuberous breast deformity. On physical examination, which of the following characteristics is most likely in this patient?
A) Absence of the sternal head of the pectoralis muscle
B) Effacement of the inframammary fold
C) Grade III ptosis of the nipple-areola complex
D) Herniation of breast tissue into the nipple-areola complex
E) Macromastia
The correct response is Option D.
Physical examination of a tuberous breast would show herniation of the nipple-areola complex. A constricted inframammary fold, rather than an effaced inframammary fold, is often associated with tuberous breast deformity. Macromastia and/or grade III ptosis of the nipple-areola complex are not standard components of tuberous breast deformity. Absence of the sternal head of the pectoralis muscle is a characteristic feature of Poland syndrome.
A 35-year-old woman with tuberous breast deformity is scheduled to undergo augmentation/mastopexy. A smooth, round, cohesive gel implant will be used. This patient is at higher risk for which of the following complications when compared with augmentation/mastopexy performed on a patient without a tuberous breast?
A) Capsule contracture
B) Double bubble
C) Hematoma
D) Nipple-areola depigmentation
E) Rippling
The correct response is Option B.
The classic features of a tuberous breast deformity include a constricted base with a high inframammary crease and herniation of breast parenchyma into the nipple-areola complex producing a large-diameter areola. Variable extent of micromastia is associated as well as breast asymmetry. When a patient has a high and tight inframammary crease, this crease must be released to accommodate an implant and allow correction of the deformity. If this native crease does not fully expand, then a double bubble will occur. Over time, the lower pole skin stretches in response to the implant and this double bubble often improves spontaneously. The incidence of capsule contracture, hematoma, nipple-areola depigmentation, and rippling should be similar to a patient who undergoes periareolar augmentation/mastopexy without a tuberous breast.
A 28-year-old woman is scheduled to undergo vertical mastopexy. She has no history of previous breast surgery. A superior pedicle technique is planned. Which of the following is the dominant blood supply for this pedicle?
A) Deep branches of the internal mammary artery from the fourth interspace
B) Deep branches of the internal mammary artery from the fifth interspace
C) Superficial branches of the internal mammary artery from the second interspace
D) Superficial branches of the internal mammary artery from the fourth interspace
E) Superficial branches of the lateral thoracic artery
The correct response is Option C.
The breast receives its arterial blood supply from multiple sources, and this fact is used to design multiple pedicles for the nipple-areola complex that can work reliably for both mastopexy and reduction mammaplasty procedures.
The superior pedicle receives its arterial blood supply primarily from the internal mammary branch from the second interspace. It is usually about 1 to 2 cm below the surface of the skin just medial to the breast meridian as it approaches the areola and may be localized with a handheld Doppler device during preoperative planning.
The inferior pedicle and central pedicle designs are primarily supplied by branches of the internal mammary system from the fourth interspace. Additionally, there is some accessory input from the intercostal branches at the level of the inframammary fold with the inferior pedicle design. These secondary vessels are typically interrupted in a central pedicle operation.
The medial pedicle design receives its arterial input mainly from the third superficial branch of the internal mammary artery. This vessel may be damaged by previous augmentation mammaplasty.
The lateral pedicle design receives its arterial supply from superficial branches of the lateral thoracic artery.
A 30-year-old woman comes to the office for augmentation mammaplasty and mastopexy after a 50-lb (23-kg) weight loss. She wears a size 38B brassiere. Physical examination shows grade II ptosis and a sternal notch to nipple distance of 26 cm bilaterally. Simultaneous augmentation mammaplasty with short-T mastopexy using smooth saline-filled breast implants that will be implanted in a dual-plane configuration through an inframammary incision is planned. Which of the following factors puts this patient at highest risk for reoperation?
A) Inframammary implant insertion route
B) Presence of breast ptosis
C) Use of drains
D) Use of saline implants
E) Use of smooth-walled implants
The correct response is Option B.
It has long been realized that combination augmentation mammaplasty operations are more difficult and have a higher revision rate than either operation alone. A recent review of 177 primary augmentation mammaplasty cases found that, of the factors listed, preexisting breast ptosis and simultaneous mastopexy were both linked to a higher rate of reoperation when possible contributing factors were statistically analyzed. Furthermore, increasing grades of breast ptosis were linked with increasingly higher reoperation rates.
Although incision site for augmentation mammaplasty has been markedly linked to the rates of capsular contracture, inframammary incisions have been shown in at least two studies to date to have the lowest rate of capsule formation, with periareolar and transaxillary incisions showing 5 to 10 times higher rates of capsule-related complications.
Which of the following is the most common complication associated with “donut” mastopexy?
A) Boxy breast shape
B) Increased distance from nipple to inframammary fold
C) Loss of nipple sensation
D) Nipple necrosis
E) Widening of the areola
The correct response is Option E.
A common complication of the “donut” (circumareolar) mastopexy is widening of the areola. This can be minimized by using a Gore-Tex suture placed using the “wagon-wheel” technique and limiting the amount of skin resected to a 2:1 ratio of outside diameter to areolar diameter.
Boxy breast shape is associated with Wise pattern mastopexy. Nipple necrosis is associated with combined augmentation and mastopexy. Increased distance from the nipple to the inframammary fold is associated with vertical mastopexies in which the height of the medial and lateral pillars is too tall. Loss of nipple sensitivity is unusual because there is no parenchymal resection.
A 65-year-old woman comes to the office 1 month before a scheduled mastopexy. Annual mammography shows a 1.5-cm mass in the upper outer quadrant. Core needle biopsy is performed. Pathologic examination of excised tissue identifies papilloma without atypia. Which of the following is the most appropriate next step in management?
A) Bilateral breast sonography
B) Excisional biopsy of needle-localized area
C) Repeat annual mammography in 12 months
D) Repeat mammography at 6-month intervals for 1 year
E) Stereotactic vacuum-assisted biopsy
The correct response is Option B.
Percutaneous biopsy methods are commonly accepted for the initial evaluation of clinically occult breast lesions, although certain nonmalignant lesions pose dilemmas with respect to the most appropriate clinical management. Papillary lesions of the breast can either be benign or malignant, although differentiation is radiologically difficult. Moreover, it is difficult for pathologists to reliably distinguish among benign, atypical, and malignant papillary lesions on the limited fragmented tissue specimens they receive after needle sampling.
Previous studies have demonstrated high rates of ductal carcinoma in situ (11%) in patients diagnosed with benign papillomas by needle biopsy and who subsequently underwent a surgical excision, although conflicting data suggest an extremely decreased rate of malignancy when histology is benign on needle biopsy.
The management of benign papillary lesions is somewhat controversial. Although conservative follow-up with either yearly mammogram or short-interval follow-up may be appropriate for certain patients diagnosed with benign papilloma, certain features of this patient’s lesion make conservative follow-up inappropriate. Sonographic follow-up in a 65-year-old woman with mature breast parenchyma and a solid mammographically detected mass would not provide much additional information, and a repeat percutaneous biopsy, whether core needle or vacuum-assisted, would also not be effective. Given the size of the lesion and the age of the patient, surgical excision is warranted despite the lack of atypia on needle biopsy. Benign papillomas tend to be smaller than 1 cm and centrally located, whereas malignant lesions are more often greater than 1.5 cm and are peripherally located.
A 28-year-old woman desires augmentation mammaplasty with silicone implants. Physical examination shows tuberous breast deformity with an elevated inframammary crease. Sternal notch to nipple distance is 21 cm bilaterally. Nipple to inframammary crease distance is 3.5 cm bilaterally. Periareolar mastopexy with 350-mL silicone implants is planned. Which of the following operative plans will most effectively minimize the likelihood of a double-bubble deformity?
A) Lower the inframammary crease by 3 cm
B) Perform radial release of the lower pole breast fascia
C) Place implants in subparenchymal pocket
D) Reinforce the inframammary crease with acellular dermal matrix
E) Use highly cohesive gel implants
The correct response is Option B.
The tuberous breast is a developmental deformity characterized by a constricted inframammary fold, short nipple to inframammary crease distance, and both horizontal and vertical deficiencies. The pathophysiology of the tuberous breast predisposes the patient to develop a double-bubble deformity. In this patient, the inframammary crease must be lowered to accommodate the implant and improve the vertical skin deficiency. Radial release of the lower pole breast fascia is done with either a cautery or a knife. Multiple radial incisions are made, thereby allowing the tight crease to expand and decrease the chance for a double-bubble deformity.
Lowering the crease is necessary but will increase the chances of a double-bubble deformity. Subparenchymal implant placement and use of highly cohesive gel implants may help but are not the essential procedures required. The use of acellular dermal matrix can help secure the position of the inframammary crease in a patient who develops a double-bubble deformity secondary to an inferior migration of the implant below the inframammary crease. This does not apply in the patient described.
A 37-year-old woman comes to the clinic to be evaluated for augmentation mammaplasty to improve her breast shape. She is gravida 3, para 3, and breast-fed all of her children. On examination, she has decreased superior pole volume, and the distance from nipple to sternal notch is 28 cm. The nipple-areola complex is below the inframammary fold by 4 cm and is at the lower contour of the breast. Which of the following Regnault classifications of ptosis best describes these findings?
A) Grade I
B) Grade II
C) Grade III
D) Pseudoptosis
The correct response is Option C.
The Regnault classification of breast ptosis is based on the relationship of the nipple to the inframammary fold (IMF) and to the lower contour of the gland.
Pseudoptosis is the not true ptosis. In this situation, the nipple is above the level of the IMF but the breast parenchyma has descended below the IMF.
Grade I is minor ptosis with the nipple at the level of the IMF and above the lower contour of the gland.
Grade II is moderate ptosis with the nipple below the level of the IMF and above the lower contour of the gland.
Grade III is major ptosis with the nipple below the level of the IMF and at the lower contour of the gland.
