Breast Augmentation, Mastopexy

A 54-year-old woman with a history of augmentation mammaplasty with textured silicone implants has histologic confirmation of breast implant-associated anaplastic large cell lymphoma (BIA-ALCL). MRI and PET scans show no associated masses, with activity localized to the periprosthetic seroma. Which of the following is the most appropriate next step in management of this patient? A) Anterior capsulectomy with removal of the implants bilaterally B) Complete capsulectomy with removal of the implant on the affected side C) Partial capsulectomy with replacement of the implant D) Removal of the textured implant and replacement with a smooth implant E) Sealing of the seroma cavity with fibrin glue

B) Complete capsulectomy with removal of the implant on the affected side Breast implant-associated anaplastic large cell lymphoma (BIA-ALCL) is a rare peripheral T-cell lymphoma that has been increasingly recognized as a serious, albeit uncommon, complication associated with the use of textured breast implants. Since the initial case report in 1996, there have been continually increasing reported cases of this rare malignancy and according to the most recent data available, the lifetime risk of association between breast implants and BIA-ALCL is between 1 in 1000 to 1 in 30,000 with the ASPS recognizing nearly 200 cases in the US and nearly 500 cases worldwide. BIA-ALCL patients typically present with a spontaneously occurring periprosthetic fluid collection or capsule-associated mass approximately 10 years following implantation of the breast implant. To date, all cases have had some association with a textured device. Initial workup includes ultrasound for evaluation of a periprosthetic fluid collection or mass. Periprosthetic fluid collections should undergo fine-needle aspiration in the clinic or ultrasound-guided aspiration by interventional radiology if there is concern for trauma to the implant while masses require tissue biopsy. Specimens should be sent for cytology with immunohistochemistry and flow cytometry for T-cell markers, specifically CD30 cell surface protein. A recent systematic review revealed that 66% of BIA-ALCL patients presented with isolated late-onset seroma while only 8% presented with an isolated new breast mass. National Comprehensive Cancer Network (NCCN) guidelines for treatment of BIA-ALCL recommend complete removal of the lymphoma (fluid and/or mass), complete capsulectomy, and removal of the implant. More advanced disease may require chemotherapy, radiotherapy, and/or lymph node dissection. Although some surgeons advocate removal of the contralateral breast implant as approximately 4.6% of cases have demonstrated incidental lymphoma in the contralateral breast, this recommendation is controversial. The official NCCN guidelines for treatment only recommend consideration of contralateral breast implant removal but this is not mandated.

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

A ) Anterior thoracic hypoplasia 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 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 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

A ) Avoiding dissection into the axillary fat 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 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

A ) Continued separation from her husband 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.

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

A ) Flatness of the upper pole 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.

Which of the following innervates the nipple-areola complex? A ) Intercostal B ) Lateral pectoral C ) Long thoracic D ) Supraclavicular E ) Thoracodorsal

A ) Intercostal 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.

A 58-year-old woman with moderate ptosis is evaluated for mastopexy. According to Regnault classification, which of the following best describes the location of the nipple-areola complex in type II breast ptosis? A) 1 to 3 cm inferior to the inframammary fold B) 4 cm inferior to the inframammary fold C) 6 cm inferior to the inframammary fold D) At or 1 cm inferior to the inframammary fold E) Superior to the inframammary fold

A) 1 to 3 cm inferior to the inframammary fold Regnault classification of breast ptosis, based on the position of the nipple-areola complex (NAC) relative to the inframammary fold (IMF): Pseudoptosis - NAC is above IMF Type I (mild) - NAC is at or 1 cm below IMF Type II (moderate) - NAC is 1 - 3 dm below IMF Type II (severe) - NAC is at the lower portion of breast The type of mastopexy performed will depend on the degree of breast ptosis. Breast ptosis is graded using Regnault classification. Type I can be treated with a crescent mastopexy, when the degree of nipple-areola complex elevation does not exceed 1 cm. Type I or II ptosis can be treated with a periareolar mastopexy, when the distance of nipple-areola complex elevation ranges from 1 to 2 cm. Type II and III ptosis is amenable to the inverted-T technique, where the horizontal incision will reduce the distance from the nipple-areola complex to the inframammary fold, while the vertical incision will reduce the base diameter.

A 28-year-old woman, gravida 2, para 2, undergoes augmentation mammaplasty 1 year post partum. On postoperative day 3, the patient comes to the office because of impaired wound healing at the incision site. Physical examination shows white viscous discharge leaking from the edge of the wound consistent with galactorrhea. Which of the following is the most appropriate management? A) Administration of bromocriptine B) Administration of metoclopramide C) Administration of trimethoprim-sulfamethoxazole D) Application of negative pressure wound therapy E) Debridement of the wound edges with wet-to-dry dressings

A) Administration of bromocriptine There are incidents of surgical procedures of the breast associated with galactorrhea leading to skin breakdown, nipple necrosis, and cellulitis. A dopamine agonist such as bromocriptine will cause decreased lactation in cases of galactorrhea/galactocele, thereby improving wound healing. Antibiotics such as sulfamethoxazole and trimethoprim (Bactrim) are generally not required, because the exudate is sterile. There is no need for debridement of the wound edges. Negative pressure wound therapy may increase lactation and galactorrhea, further impairing wound healing. Metoclopramide is a dopamine antagonist used for nausea and vomiting.

An otherwise healthy 25-year-old woman is evaluated and scheduled for augmentation mammaplasty with silicone gel implants. Which of the following is most accurate regarding breast implant-associated anaplastic large cell lymphoma (BIA-ALCL)? A) All late breast implant-associated seromas should be evaluated B) BIA-ALCL is most often associated with an aggressive clinical course C) BIA-ALCL is most often associated with smooth implants D) It is not necessary to include BIA-ALCL in a standard breast augmentation/reconstruction consent E) Knowledge about BIA-ALCL's cause is based on strong evidence-based studies

A) All late breast implant-associated seromas should be evaluated Due to the potential critical relevance of breast implant-associated anaplastic large cell lymphoma (BIA-ALCL) and its tendency to present as a late seroma, correct diagnostic pathways should be carried out on all late breast implant-associated seromas to include cytologic examination and, if indicated further, fine-needle aspiration, flow cytometry, and immunohistochemistry for CD30. BIA-ALCL is a critical outcome in implant-associated breast augmentation/reconstruction. It is most commonly confined to peri-implant seroma fluid and follows a nonaggressive course amenable to implant and capsule removal, although there are aggressive variants. Discussion about this condition should be part of the consenting process for all breast implant cases. Finally, to this point evidence on cause is based on very low-evidence studies. ALCL is most often associated with textured implants.

A 24-year-old woman with bilateral micromastia comes for consultation regarding augmentation mammaplasty. The patient says she would like her breasts to be "as big as possible." On examination, which of the following is the most important factor in determining the maximum acceptable prosthesis size for this patient? A) Breast base width B) Diameter of the areola C) Grade of nipple-areola ptosis D) Maximum manufactured prosthesis volume E) Pectoralis muscle height-to-prosthesis height ratio

A) Breast base width The most important factor in determining the maximum acceptable prosthesis size in this patient is breast base width. Grade of nipple-areola ptosis, areola diameter, maximum manufactured prosthesis volume, and pectoralis height may all impact overall appearance of the breast but do not have an impact on breast prosthesis size choice.

A 28-year-old postpartum woman comes to the office for evaluation of breast asymmetry with pain and enlargement of the right breast for 2 months. Medical history includes augmentation mammaplasty 4 years ago. She denies fever or chills. She was previously breast-feeding but stopped this 1 month ago. Physical examination shows the right breast is significantly larger than the left breast. A well-healed peri-areolar incision is present and no evidence of infection is noted. Ultrasound shows a complex cyst, which yields 150 cc of milky fluid. A drain is placed. The most appropriate next step is administration of which of the following medications? A) Bromocriptine B) Cephalexin C) Fluconazole D) Prolactin E) Trimethoprim-sulfamethoxazole

A) Bromocriptine This postpartum patient is presenting with a symptomatic galactocele after breast-feeding. Galactoceles are benign breast cysts containing milk. They typically occur in women of childbearing age in the setting of active lactation, recent pregnancy, or the use of hormonal medications such as oral contraceptives. The galactocele is thought to occur from ductal obstruction. Although the presence of a breast implant and the respective pocket placement is unknown to have an effect on the development of galactoceles, there is some thought that peri-areolar incisions may contribute to the ductal obstruction. There are, however, documented cases of post-augmentation galactocele without peri-areolar incisions. Treatment for a galactocele is typically medical with the initiation of oral bromocriptine. Bromocriptine is a dopamine receptor agonist and causes inhibition of prolactin secretion, which is the primary hormone responsible for milk production. Dosage is titrated to effect. Incision and drainage of the cyst, particularly in the setting of implants, is often performed as well to rule out the possibility of infection. Cephalexin and trimethoprim-sulfamethoxazole are antibiotics and are not indicated in this case because there is no active infection. Fluconazole is indicated for the treatment of fungal infections. Prolactin would actually stimulate milk production and would worsen the patient's symptoms.

A 28-year-old woman comes to discuss primary augmentation mammaplasty options and is deciding between form-stable shaped implants and less cohesive round silicone gel implants. She inquires about the benefits of each type of implant. Compared with smooth round silicone gel implants, highly cohesive form-stable gel implants have a decreased incidence of which of the following? A) Capsular contracture B) Implant malposition C) Infection D) Seroma

A) Capsular contracture Form-stable silicone gel implants are fifth-generation, shaped, and textured implants that have additional cross-linking between molecules. They are purported to have several advantages over other round saline and silicone gel implants because they retain their shape and decrease the incidence of folding and rippling. This has translated into significantly lower capsular contracture rates. However, they do have some disadvantages. Because they are shaped and maintaining orientation is critical, they have a higher incidence of malposition. They are also more prone to seroma formation, which may be associated with their textured surface. Infection and resorption rates remain similar.

A 24-year-old nulliparous woman comes to the office for augmentation mammaplasty. She currently wears a size 34B brassiere and wants her brassiere size to be increased to a D cup. She is a good candidate for subglandular placement of implants. Which of the following risks is decreased by the use of the textured silicone shell compared with the smooth silicone shell? A) Capsular contracture B) Hematoma C) Prosthesis malposition D) Rippling E) Symmastia

A) Capsular contracture Texturing of the implant surface has been shown to decrease the rate of capsular contracture when compared with smooth implants when the implants are placed in the subglandular position. The benefit of textured implants may not be present when the implants are placed in a submuscular pocket. There is no difference in hematoma rates for textured versus smooth implants. Both symmastia and implant malposition are related to pocket dissection and not related to the type of implant placed. In the case of symmastia, the pockets have encroached upon the sternum and are close to each other or are touching. Implant malposition can be related to factors such as inadequate dissection of the pocket, or over-dissection of the pocket. Finally, some studies have demonstrated an increase in rippling with textured implant when compared with smooth implants. However, rippling may be more related to cohesiveness of the gel and fill volumes of the shell, because early reports of experience with the form-stable implant (Natrelle 410) seem to show decreased rates of rippling.

A 40-year-old woman who underwent a subglandular augmentation mammaplasty with smooth round silicone breast implants 5 years ago returns to the office for evaluation of an increasingly firm left breast. Surgical revision of the left breast is planned. Which of the following measures is most likely to decrease the recurrence of the symptoms? A) Conversion to a new plane or pocket B) Performing a total capsulectomy C) Using botulinum toxin type A in and around the implant pocket D) Using fat grafting in and around the implant pocket

A) Conversion to a new plane or pocket Site change and implant exchange are the only factors that have consistently been shown to decrease recurrence of capsular contracture, although other factors including use of a textured implant and fat grafting used are in augmentation mammoplasty revision. Botulinum toxin type A has been described for prevention of capsular contracture however; no consensus that these treatments decrease recurrence of capsular contracture exists. Furthermore, there are no data to support performing total versus partial capsulectomy, or even the superiority of capsulectomy over capsulotomy.

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 B) Less capsular formation C) Less wrinkling D) Lighter prosthesis E) Lower risk of leakage

A) Easier detection of rupture 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 55-year-old postmenopausal woman desires improvement in the appearance of her breasts. Change in which of the following levels of hormones is most likely responsible for postmenopausal involution of breast tissue? A) Estrogen B) Growth hormone C) Oxytocin D) Prolactin E) Testosterone

A) Estrogen Estrogen is the primary hormone in promoting the development of the breast epithelium and ductal tissue. Progesterone acts in combination with estrogen to regulate breast development. With the onset of menopause, there is a decrease in the secretion of estrogen and progesterone. As a result of the decrease in the circulating levels of these hormones, the breast undergoes regression and atrophy of the glandular elements. Oxytocin and prolactin are hormones involved in the physiology of lactation. Growth hormone and testosterone may have an effect on breast tissue, but they are not primary factors in the physiology of the female breast.

An otherwise healthy 28-year-old woman comes to the physician requesting removal of bilateral axillary masses. She states that the masses fluctuate in size and tenderness with her menstrual cycle. She reports that the masses have not had discharge or drainage. Physical examination shows smooth, spongy masses in both axillae. A photograph is shown. Which of the following is the most appropriate next step in management of this patient? A) Excise the bilateral axillary masses and skin B) Obtain bilateral mammograms of the axillary masses C) Order an MRI of the chest D) Perform a core biopsy of both axillary masses E) Perform liposuction

A) Excise the bilateral axillary masses and skin This patient presents with ectopic breast tissue. In utero, the milk line (galactic band) forms at 5 weeks of gestation. This bilateral structure courses from the axillae to the groin, and normal breasts form in the prepectoral region after there has been regression of the rest of the galactic band. When there is failure of this regression, breast tissue remains in locations outside of the normal breast. The most common location for ectopic breast tissue is in the axillae, although it can be found anywhere along the milk line from the axillae to the groin. Ectopic breast tissue outside of the milk line has been described and is termed aberrant breast tissue. The tissue found in these ectopic locations is breast tissue with the same characteristics and propensity for disease as normally located breast tissue, and breast cancer has been described in these tissues. In the absence of pathologic findings such as a mass, pain, and skin changes that are associated with breast cancer, there is no strong oncologic indication for excision. If there are findings concerning for a neoplasm, then work-up should be initiated and might include further imaging, core biopsy, and surgery. However, most cases present without pathologic findings and are excised to achieve a more reasonable appearance for the patient, the ability to don clothing more comfortably, and for the obvious social advantages. In this case, the patient is young, has no complaints, and has no physical findings to suggest a neoplasm. Excision should be offered. Obtaining bilateral mammograms is incorrect because there is no indication for imaging in this patient based on her age, history, and physical examination. In addition, mammograms of axillary breast tissue are technically unfeasible. Performing a core biopsy is incorrect as there is no concern for malignancy in this case. In the case of a mass noted within the ectopic axillary breast tissue, then an oncologic workup should be initiated which might include a core biopsy. An MRI of the chest is incorrect because there is no indication for imaging in this patient based on her age, history, and physical examination. Reassuring the patient with no further action is not the most appropriate management, as it will not address the patient's concerns and desires. In the patient who does not request excision or is not an appropriate surgical candidate, then reassurance and surveillance are appropriate. As this is a young female with axillary breast tissue, liposuction will not improve the excess breast tissue or skin.

A 23-year-old woman with micromastia and bilaterally tuberous breasts comes to the office to discuss augmentation mammaplasty and improving the overall appearance of her breasts. Physical examination shows bilateral mildly ptotic breasts with glandular tissue herniating through the nipple-areola complex. The lower pole appears mildly deficient in the lower medial and lateral quadrants, and the distance from the nipple to the inframammary crease is 5.5 cm on stretch. Which of the following is the most appropriate operative approach for this patient? A) Implant placement with circumareolar mastopexy B) Implant placement without mastopexy C) Implant placement with vertical mastopexy D) Implant placement with Wise-pattern mastopexy E) Two-stage reconstruction with tissue expander, followed by placement of a permanent implant

A) Implant placement with circumareolar mastopexy The tuberous breast deformity was first described by Aston and Rees in 1976. While most of the surgical approaches listed, with the exception of implants together with Wise-pattern mastopexy, have been described for the spectrum of tuberous breast deformities, the key is to select the right procedure for the right patient. In this case, a mild form of the deformity is described. Implant placement alone, even with parenchymal scoring and lowering of the inframammary crease, is unlikely to correct the deformity of the nipple-areola complex. In cases of severe ptosis, vertical mastopexy may be used but would be unnecessary in this patient with mild ptosis. In severely deficient cases, a two-stage approach with tissue expansion may be necessary, but it would be over-operating in this mildly deficient patient. Recently, fat grafting has also been advocated for this procedure. In the case described, which is a common presentation, a periareolar approach is typically used to place the implant in a dual-plane configuration. Subglandular placement is also described. The inframammary crease is commonly adjusted downward. Radial scoring of the parenchyma and a circumareolar mastopexy are typically performed. In the recent review by Kolker and Collins, 92% of tuberous breast patients had a one-stage procedure. Ninety-six percent of these were treated with implant placement and circumareolar mastopexy, combined with inframammary crease adjustment and radial scoring of the parenchyma.

An otherwise healthy 40-year-old woman comes to the office for augmentation mammaplasty. Mammography 6 months ago showed no abnormalities. Family history is negative for breast cancer. She wants to know if silicone gel implants are safe and what she should do after the procedure to monitor the implant for evidence of rupture. According to the current federal guidelines, which of the following is the most appropriate recommendation to this patient regarding surveillance? A) MRI 3 years after implantation and every 2 years thereafter B) MRI every 10 years C) MRI if symptoms such as chronic myalgia and fatigue develop D) Yearly mammograms E) Yearly MRI

A) MRI 3 years after implantation and every 2 years thereafter Evidence-based data to confirm the validity of screening patients with silicone implants are lacking. In 2011, the FDA issued recommendations for physicians on the use of silicone gel-filled implants. Recommendations included providing copies of educational brochures, giving appropriate informed consent, maintaining medical vigilance, and reporting adverse events. It also suggested that patients undergoing augmentation mammaplasty get an MRI 3 years after implant placement and every 2 years thereafter. The purpose of these recommendations is not to replace routine cancer surveillance.

A 35-year-old woman comes to the office with her boyfriend for consultation regarding augmentation mammaplasty. She currently wears a size 34B brassiere and is considering having her brassiere size increased to a D cup. She says she is happy with the way she looks in clothes, but the boyfriend indicates he would like to see a little more cleavage when she is in a swimsuit. History includes liposuction of her lateral thighs 6 months ago by a local dermatologist; she was satisfied with the result. She has also had injection of botulinum toxin type A to the glabella 3 times in the last year. Which of the following is the best reason to refuse performing the procedure for this patient? A) The patient may be being pushed into surgery B) The patient may be a "surgiholic" C) The patient may have body dysmorphic disorder D) The patient may have a personality disorder E) The patient may have unrealistic expectations

A) The patient may be being pushed into surgery Most aesthetic surgeons and mental health professionals agree that patients who exhibit even mild signs of psychiatric problems are not good candidates for aesthetic surgery. Many patients present without obvious signs of problems and are unfortunately discovered when postoperative problems arise. However, there are certain groups of patients with easily identifiable characteristics that constitute a red flag: those who are pushed into surgery by others, those with whom you are incompatible, the ?surgiholic? with a long past surgical history, those facing marital or familial disapproval, those with body dysmorphic disorder, the overly demanding patient, and those with unrealistic expectations.

A 32-year-old woman comes to the office for consultation regarding augmentation mammaplasty. She is concerned about the potential complications with the use of silicone gel prostheses within the first 5 years postoperatively. Which of the following is the most commonly reported complication of the implantation of cohesive silicone gel breast prostheses? A)Capsular contracture B)Granuloma C)Hematoma D)Infection E)Rupture

A)Capsular contracture Cohesive silicone gel is a breast prosthesis option that has been approved by the FDA since 2006. Cohesive gel prostheses have also been called ?gummy bear? prostheses. They maintain their shape because of the increased cross-linking within the silicone gel. A study by Cunningham followed 1008 patients and 1898 cohesive gel prostheses. Rupture rate was 1.1% for aesthetics and 3.8% for reconstructive procedures. Capsular contracture rates (Baker III/IV) were 9.8/13.7%, and infection was 1.6/6.1%, respectively. Thus, capsular contracture was the most common of the listed complications. The reported incidence of hematoma is approximately 2%. It should be noted that complications occur more commonly in primary reconstruction as compared to primary augmentation. These findings are important in the preoperative counseling of patients.

A 47-year-old woman, gravida 2, para 2, who has grade III breast ptosis is evaluated for mastopexy. Attenuation of which of the following structures is the most likely cause of the ptosis? A) Breast acini B) Cooper ligaments C) Lactiferous ducts D) Scarpa's fascia E) Subdermal plexus

B) Cooper ligaments Breast ptosis is a complex interaction of events, informed by breast size, gravity, aging, lactation, and parity. It occurs through a combination of atrophy of the breast tissue, loss of elasticity of the skin envelope, and attenuation of Cooper ligaments. While the breast is surrounded by fascia, the continuation of Scarpa's fascia forms the posterior capsule of the breast. The lactiferous ducts and breast acini do not contribute significantly to ptosis. Subdermal plexus provides vascularity rather than support to the breast.

A 23-year-old woman undergoes augmentation mammaplasty with round, smooth silicone implants placed in the dual-plane position. Postoperatively, unilateral erythema and warmth are noted, and they slowly resolve over 10 days of oral antibiotic treatment. The patient asks what this might mean for future satisfaction with the outcomes. Which of the following is the most likely sequela of this patient's clinical course? A) Breast gland ptosis B) Capsular contracture C) Double-bubble appearance D) Implant rupture E) Nipple numbness

B) Capsular contracture One of the most often mentioned potential risk factors for capsular contracture is biofilm, and this may be related to bacterial contamination. History of infection is unlikely to impact nipple sensation, implant rupture, true breast gland ptosis, or effacement of the inframammary fold with downward descent of the implant.

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

B ) A mother diagnosed with breast cancer at age 45 years 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 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

B ) Linguine sign 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 25-year-old woman comes to the office because of a 1-week history of erythema and clear drainage from the right breast 6 weeks after undergoing bilateral augmentation mammaplasty. She is afebrile and her vital signs are within normal limits. The drainage from the breast is sent for cultures. Broad-spectrum antibiotics are administered, but no improvement is noted over the next 48 hours. Surgical debridement and explantation of the prostheses are performed. After 7 days, cultures grow Mycobacterium fortuitum. Which of the following is the most appropriate next step? A) Administration of ciprofloxacin and trimethoprim-sulfamethoxazole for 6 weeks B) Administration of ciprofloxacin and trimethoprim-sulfamethoxazole for 6 months C) Administration of isoniazid, rifampicin, and pyrazinamide for 6 weeks D) Administration of isoniazid, rifampicin, and pyrazinamide for 6 months E) No antibiotic therapy is needed because the infected prostheses have been removed

B) Administration of ciprofloxacin and trimethoprim-sulfamethoxazole for 6 months The most appropriate next step in management is to initiate a 6-month course of ciprofloxacin and trimethoprim-sulfamethoxazole (Bactrim). Mycobacterium fortuitum is an atypical, nontuberculous mycobacterium (NTM), and it is one of the most common causes of NTM soft-tissue infections. It occurs most commonly in the presence of foreign bodies, such as breast prostheses. The incidence of these opportunistic infections has increased over the years. NTM infections can be more indolent and manifest weeks, or even months, following surgery. They occur most commonly with erythema, swelling, and clear drainage, although purulence may be seen. Fever may be absent. On surgical exploration, exuberant granulation tissue and turbid, odorless fluid are often noted. Routine Gram stains and cultures are usually negative. Therefore, it is imperative to request acid-fast bacilli staining and mycobacterial cultures if suspicion of NTM infection is high. Removal of the prosthesis and thorough debridement of the periprosthetic space, followed by long-term (3 to 6 months) antibiotic therapy, is required to treat this infection. Culture sensitivities should guide the antibiotic regimen, but ciprofloxacin, trimethoprim-sulfamethoxazole (Bactrim), clarithromycin, and doxycycline are used commonly for treatment. Reimplantation of the prosthesis should not be considered for a period of at least 6 months. Isoniazid, rifampicin, and pyrazinamide are standard antibiotics used to treat tuberculosis caused by Mycobacterium tuberculosis, not atypical mycobacteria. Although removal of the affected prosthesis is required, long-term antibiotic therapy is an essential part of the treatment.

A 13-year-old girl is evaluated for breast asymmetry. Examination shows total absence of the left mammary gland tissue, with normal areola and nipple. Pectoral muscles are normal. No hand, facial, or other body abnormalities are noted. Which of the following is the most likely diagnosis? A) Amastia B) Amazia C) Athelia D) Ectodermal dysplasia E) Poland sequence

B) Amazia There are a number of uncommon aplastic deformities of the breast. These include: total absence of the breast and nipple (amastia), absence of the nipple (athelia), and absence of the mammary gland (amazia), as described in this case. These anomalies may occur in isolation, or may be associated with various syndromes, such as Poland syndrome, where the absence of the breast is associated with absence of the pectoralis major muscle, rib cage and ipsilateral upper limb deformities. Ectodermal dysplasias can affect the breast, but two or more abnormalities of ectodermal structures - hair, teeth, nails, sweat glands, craniofacial structures - would be required to consider the diagnosis.

A 45-year-old woman comes to the office 10 years after undergoing subglandular implantation of textured silicone implants for augmentation mammaplasty. Physical examination shows swelling of the left breast. She is concerned about cancer. Increased incidence of which of the following malignancies is associated with breast implants? A) Acute myeloid leukemia B) Anaplastic large cell lymphoma C) Angiosarcoma D) Infiltrating ductal carcinoma E) Malignant fibrous histiocytoma

B) Anaplastic large cell lymphoma Several reports have suggested an association between breast implants and anaplastic large cell lymphoma (ALCL), which is an extremely rare malignancy. In these cases, ALCL has usually occurred several years after implantation as swelling or a mass around the implant and is often associated with a periprosthetic seroma. Treatments have included capsulectomy with implant removal and chemotherapy and/or radiation therapy, though there is no defined consensus regimen. Despite evidence of an increased risk of ALCL in breast implant patients, the absolute risk remains extremely low. Several large epidemiologic studies have demonstrated a similar or lower incidence of breast cancer (infiltrating ductal carcinoma) among patients who have undergone prosthetic augmentation mammaplasty surgery compared with those who have not. Most cases of ALCL have been in textured implants. Angiosarcoma and malignant fibrous histiocytoma are two sarcomas that may arise in the breast. Angiosarcoma may be caused by radiation therapy for breast cancer. Neither of these sarcomas has been associated with breast implants. Acute myeloid leukemia may be associated with radiation treatment to the breast but has not been associated with breast implants.

A 35-year-old woman is evaluated because of swelling of the right breast 3 years after undergoing augmentation mammaplasty. The implant type is unknown. Ultrasonography shows a seroma, and a fine-needle aspiration is performed. Which of the following immunohistochemical stains of the aspirate is most appropriate? A) CCD79a B) CD30 C) CK20 D) E-cadherin E) p63

B) CD30 Patients who present with a late seroma should be evaluated for possible breast implant-associated anaplastic large cell lymphoma (BI-ALCL). A late seroma is usually accepted as occurring 1 year following surgery; however, there are cases of BI-ALCL seromas that have presented as early as 4 months. The first step in evaluating BI-ALCL is ultrasonography, followed by fine-needle aspiration if indicated. The fluid requires evaluation beyond routine cell cytology. Immunohistochemistry test for CD30 was the most commonly positive marker for BI-ALCL. Immunohistochemistry stains specific antigens in cells by binding to this antigen in an antibody/antigen reaction. The specific stain can then be seen under light microscopy. The CD30 antibody labels anaplastic large cell lymphoma cells. CD30 is a transmembrane cytokine receptor belonging to the tumor necrosis factor receptor family. CK20 and CCD79a were negative for tested BI-ALCL specimens. P63 stains myoepithelial cells and is used to rule out invasive breast tumors. E-cadherin helps distinguish ductal from lobular carcinoma.

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

B) Double bubble 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 30-year-old woman comes to the office because of a 3-week history of unilateral swelling of the left breast. She underwent subglandular placement of textured silicone breast implants 4 years ago. She has had no trauma, fevers, or chills. A 1-week course of an oral antibiotic prescribed by her family physician has failed to resolve the swelling. On physical examination, the left breast is 300 to 400 mL larger than the right breast. No other abnormalities are noted. Ultrasonography report shows seroma and results are negative for hematoma or mass. Which of the following is the most likely diagnosis in this patient? A) Anaplastic large cell lymphoma B) Double capsule phenomenon C) Giant fibroadenoma of the breast D) Hematoma due to capsule tear E) Periprosthetic abscess

B) Double capsule phenomenon The combination of late-onset swelling without signs of periprosthetic infection (fever, cellulitis), no history of trauma, and a negative ultrasonography suggests late-onset seroma, as can occur with a double capsule phenomenon. Late seromas occur as a complication in about 1% of reported breast implant series. This issue seems to be more common in the setting of textured implants, particularly those implants manufactured with an aggressive texturing process. At surgery, a capsule layer is seen lining the pocket, which often contains a substantial volume of serosangineous seroma fluid and a textured implant coated in a tight second capsule at the center of the pocket. Double capsule has been reported in both the subglandular and submuscular positions. A giant fibroadenoma of the breast would have a dominant mass, distortion of the breast shape, and would be visible on ultrasonography. Abscess would be likely to occur with fever, chills, and cellulitis of the breast. Hematoma of this size would be likely to have a history of trauma, breast pain, and external bruising. Although anaplastic large cell lymphoma is a possibility in the differential of late-onset seromas, it is a rare disorder. Seroma fluid, obtained either by ultrasound-guided aspiration or at the time of open surgery, should be sent for cytologic examination and immunohistochemistry to rule out this rare possibility.

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

B) Excisional biopsy of needle-localized area 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 34-year-old woman with a history of grade I breast ptosis who is 6 years status post-augmentation mammaplasty with subglandular gel-filled implants returns to the clinic. Physical examination shows normal-appearing breasts, but there is mild firmness on palpation. Which of the following Baker grades best describes these findings? A) Grade I B) Grade II C) Grade III D) Grade IV

B) Grade II Many classification systems have been used to evaluate the severity of breast capsular contracture, which occurs when the peri-implant capsule undergoes fibrotic change. The most widely employed assessment tool remains the Baker grading system, which takes into account patient signs and symptoms. According to the Baker classification, only the highest degrees of contractures (grades III and IV) require surgical treatment. The descriptors for each grade are listed here: Grade I: the breast is soft and appears normal in size and shape Grade II: the breast is a little firm and appears normal Grade III: the breast is firm and appears abnormal Grade IV: the breast is firm, appears abnormal, and is painful Studies note decreased relative risk for Baker grade III to IV capsular contracture in patients who undergo primary breast augmentation through an inframammary fold incision, subpectoral pocket placement, and textured implants. There is an increased relative risk for capsular contracture when patients undergo a periareolar or axillary incision and subglandular placement of smooth implants.

The mammary glands develop from which of the following embryologic structures? A) Bilateral mesenchymal condensations B) Ingrowths from the ectoderm C) Ingrowths from the mesoderm D) Proliferating masses of endoderm E) Proliferating masses of mesenchyme

B) Ingrowths from the ectoderm The breasts, or mammary glands, are modified sweat glands. They are ingrowths from the ectoderm that form the lactiferous ducts and alveoli. They begin as linear mammary ridges with 15 to 20 buds. During the seventh week in utero, these buds undergo apoptosis, leaving a single pair of solid buds—the primary mammary buds—at the fourth or fifth intercostal space. Proliferating masses of mesenchyme are at the center of each limb bud. The mesoderm gives rise to organs, musculature, vasculature, and connective tissues. The endoderm becomes the epithelial lining of the alimentary tract. Bilateral mesenchymatous condensations develop into the sternum.

A 38-year-old woman reports decreased areola sensitivity after undergoing mastopexy. Intraoperative injury to which of the following nerves is the most likely cause of this patient's reduced sensitivity? A) Intercostobrachial nerve B) Lateral cutaneous branch of the fourth intercostal nerve C) Lateral cutaneous branch of the sixth intercostal nerve D) Medial cutaneous branch of the fifth intercostal nerve E) Medial cutaneous branch of the third intercostal nerve

B) Lateral cutaneous branch of the fourth intercostal nerve The lateral cutaneous branch of the fourth intercostal nerve is most commonly responsible for nipple and areola sensitivity. The other intercostal nerve branches listed do contribute to breast sensitivity but are less often thought to be the primary innervation to the nipple and areola. The intercostobrachial nerve supplies innervation to the upper medial arm.

A 43-year-old woman comes to the office for consultation regarding augmentation mammaplasty. She has never had any lumps or nipple discharge from her breasts, and has no family history of breast cancer. After discussion, she chooses saline prostheses. She is concerned about breast cancer and inquires about screening. Which of the following screening studies is most appropriate for this patient after augmentation? A) CT scan B) Mammography C) MRI D) Positron emission tomography E) Ultrasonography

B) Mammography Current recommendations for breast cancer screening in women with augmentation mammaplasty include mammography with Eklund views. In the Eklund technique, the prosthesis is pushed back against the chest wall, and the breast tissue is pulled forward and around the prosthesis. The use of this technique increases the sensitivity of mammography for breast cancer. Breast prostheses may affect the visualization of breast tissue, and it has been suggested that diagnostic mammography be obtained instead of screening mammography, even for the asymptomatic patient. CT scanning has been studied for the evaluation of the breast but is not routinely used as a tool for breast imaging. MRI is recommended for the evaluation of a ruptured silicone prosthesis. The technique has high sensitivity, but lower specificity and high cost. It is not recommended as a screening tool for breast cancer in the general population at this time, but it may play a role in the high-risk patient. Positron emission tomography is not used as a screening test for breast cancer. It is often used as an adjunct in patients diagnosed with breast cancer to determine if the cancer has spread to the lymph nodes or other parts of the body. Ultrasonography may be used for screening but is not recommended because it is very operator dependent. It will often be used as an adjunct to mammography in screening or if a suspected lesion is found.

A 47-year-old woman, gravida 3, para 3, is evaluated for improvement of breast appearance. She breast-fed all three of her children for 1 year each. Examination shows the distance from nipple to sternal notch is 27 cm bilaterally; decreased superior pole volume, and striae are also noted. There is Grade 3 ptosis bilaterally. The pinch of the superior pole soft tissue is 1 cm. Which of the following procedures is most likely to improve superior pole volume and breast shape in this patient? A) Dual-plane implant augmentation B) Mastopexy with dual-plane implant augmentation C) Mastopexy with subglandular implant augmentation D) Subglandular implant augmentation E) Vertical mastopexy

B) Mastopexy with dual-plane implant augmentation Goals of improvement would be upper pole fullness and a coned, rounded breast, with raising the nipple. Because the superior pole thickness is less than 2 cm, a subglandular implant is not recommended. A dual-plane implant would not address the ptosis and would likely leave persistent ptosis. Vertical mastopexy alone would require some modification to address the excess vertical skin with some element of horizontal inferior excision. This would not address the lack of upper pole volume in the long term. The striae indicate poor tissue strength. Staged implant placement would have the fewest risks.

A 48-year-old woman, gravida 3, para 3, who wears a size 36B bra comes to the physician for evaluation of breast ptosis. BMI is 24 kg/m2. Physical examination shows the distance from sternal notch to nipple is 28 cm, and there is grade 2 breast ptosis with skin laxity. A combined augmentation/mastopexy is planned. Which of the following is the biggest risk of combining the procedures rather than staging them? A) Hematoma B) Need for revision procedure C) Nipple-areola complex necrosis D) Seroma E) Transection of lateral intercostal nerves

B) Need for revision procedure The correct response is Option B. Combining an augmentation with a mastopexy has long been considered risky because the surgeon is addressing two opposing forces during the same operation: the ptosis and volume, for which the placement of additional weight may exacerbate ptosis. Studies have shown, however, that the two operations can safely be combined. During the planning, particularly for severe ptosis, the surgeon must be careful not to overresect skin that will be critical for closure over an implant. Compared with staged procedures, mastopexy-augmentation has a higher rate of need for revision procedures. Patients should be counseled about the potential need for revisions. Seroma and hematoma are not increased when combining the procedures, and nipple-areola complex necrosis is a function of pedicle size and patient-specific factors such as obesity and tobacco use, rather than the combination of procedures. Similarly, transection of intercostal nerves is associated more closely with pedicle type than with combining procedures.

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

B) Nipple to inframammary crease 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 40-year-old woman comes to the office for consultation on an augmentation mastopexy 2 years after giving birth to her second child. She is back to her pre-pregnancy weight. Physical examination shows involutional changes contributing to a deflated appearance of the breasts. This appearance is most likely due to a histologic decrease in which of the following? A) Area composed of stromal matrix B) Number of differentiated lobules C) Thickness of dermis D) Thickness of pectoralis muscle E) Volume of adipose tissue

B) Number of differentiated lobules Postpartum involutional changes can manifest clinically as breasts that appear deflated, commonly due to a loss of volume and skin that has been stretched. On a histologic level, these clinical manifestations occur due to a decrease in the number and area of differentiated lobules that were enlarged and specialized for milk production. As this occurs, it is hypothesized that the lobular area is then replaced by stromal matrix and eventually fat. Involutional changes do not refer to changes in the dermis, pectoralis muscle or chest wall structures.

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

B) Perform radial release of the lower pole breast fascia 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.

Which of the following is most commonly associated with decreased incidence of capsular contracture? A) Formation of biofilm B) Placement of textured silicone device C) Subglandular placement of the implant D) Use of a periareolar incision E) Use of a postoperative surgical brassiere

B) Placement of textured silicone device The rest of the options have been shown to increase the incidence of capsular contracture. Textured silicone implants, inframammary incisions, and submuscular implant placement have been shown to decrease the incidence of capsular contracture. The use of a surgical brassiere postoperatively has not been shown to decrease incidence of capsular contracture as well.

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

B) Presence of breast ptosis 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.

In embryologic breast development, which of the following best describes the formation of the mammary ridge? A) Starts at the fifth or sixth week of fetal development, when buds of mesoderm grow into the overlying ectodermal skin layer B) Starts at the fifth or sixth week of fetal development, when outgrowths from the ectodermal skin layer penetrate into the mesoderm C) Starts at the seventh or eighth week of fetal development, when buds of mesoderm grow into the overlying ectodermal skin layer D) Starts at the seventh or eighth week of fetal development, when outgrowths from the ectodermal skin layer penetrate into the mesoderm E) Starts at the third or fourth week of fetal development, when buds of mesoderm grow into the overlying ectodermal skin layer

B) Starts at the fifth or sixth week of fetal development, when outgrowths from the ectodermal skin layer penetrate into the mesoderm Muntan, et al. described breast development as starting at the fifth or sixth week of development, when outgrowths from the ectodermal skin layer penetrate into the underlying mesoderm, forming the mammary ridge or milk line. The ectodermal thickenings along the mammary line regress between gestational months 2 and 4, except for two of them in the region of the third and fourth ribs. The ectoderm keeps on extending into the underlying mesoderm at the fifth month, and a branching network forms what will eventually become the lactiferous system. The supportive connective and adipose tissue of the breast develops from the surrounding mesenchyme.

In augmentation mammaplasty, which of the following is the ideal upper pole to lower pole anatomic ratio? A) 25:75 B) 35:65 C) 45:55 D) 50:50 E) 55:45

C) 45:55 Studies have demonstrated the ideal anatomical characteristics of the breast to include: an upward pointing nipple, a straight or mildly concave upper pole slope, smooth lower pole convexity and fuller lower pole compared to upper pole. Breasts with an upper pole-to-lower pole ratio of 45:55 were identified as defining the ideal breast. The ratio was defined ideal by respondents including women, men, plastic surgeons, and individuals of ethnic diversity.

A 35-year-old woman is evaluated for long-term follow-up 9 years after undergoing bilateral augmentation mammaplasty for hypomastia by another surgeon. The mammaplasty was performed with 450-mL smooth, round, silicone subglandular implants. The patient recently found out she is BRCA2 positive and underwent MRI of the breasts as part of a surveillance study. The MRI showed a "linguine sign" in the right breast. Which of the following findings on physical examination is most consistent with the diagnosis associated with the "linguine sign"? A) The right breast has more rippling than the left breast B) The right breast is not significantly different from the left breast C) The right breast is significantly larger than the left breast D) The right breast is significantly smaller than the left breast

B) The right breast is not significantly different from the left breast The right breast is not significantly different from the left breast. The linguine sign describes multiple low-signal curvilinear lines on MRI that correlated to the collapsed implant shell. It is an indication of intracapsular rupture. Physical examination alone is not specific or sensitive enough to diagnose all cases of intracapsular rupture. Ultrasound and/or MRI is recommended. The physical examination finding of one breast that is smaller, firmer, and higher than the other is indicative of capsular contracture. MRI is not a sensitive predictor of capsular contracture. A right breast that is significantly larger than the left breast would indicate a late seroma and a workup for breast implant-associated anaplastic large-cell lymphoma would be indicated. A right breast that is significantly smaller than the left breast would be indicative of a ruptured saline implant. Increased rippling is not expected with an intracapsular rupture.

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

B) Third and fourth 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 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

B)Application of a circumferential breast band 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 24-year-old woman comes to the office to discuss augmentation mammaplasty. She is interested in subglandular implant placement and would like to discuss the risks of augmentation. Which of the following risks is more likely with smooth round silicone implants compared with textured anatomic silicone implants? A) Anaplastic large cell lymphoma B) Capsular contracture C) Double capsule D) Late seroma E) Malrotation

Capsular contracture is more common in smooth round silicone implants than in textured implants. It is believed that the texturing of the implant is protective against significant capsule formation. On the other hand, there are several increased risks associated with textured anatomic implants. These include increased risks of late seroma and breast implant-associated anaplastic large cell lymphoma (BIA-ALCL), although this is very rare. Double capsule is a complication more recently noted with the introduction of textured anatomic implants. Malrotation can only be seen in an anatomic textured implant, because smooth round implants are symmetric in shape. In addition, it can be difficult to differentiate between anatomic shaped and smooth round implants, with several studies showing their similar cosmetic outcomes.

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

C ) Mastopexy and placement of 450-mL saline prostheses in a dual-plane pocket 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.

65. 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

C ) Saline prostheses 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.

A 53-year-old woman comes to the office because of unilateral swelling of the breast 5 years after undergoing subglandular augmentation mammaplasty. A diagnosis of anaplastic large T-cell lymphoma (ALCL) is established. Which of the following is most likely to represent the progression of this patient's disease when compared with a patient who has ALCL but no breast prostheses? A) A more aggressive clinical course and a poorer prognosis B) A more aggressive clinical course but a more favorable prognosis C) A more indolent clinical course and a more favorable prognosis D) A more indolent clinical course but a poorer prognosis E) The same clinical course and prognosis

C) A more indolent clinical course and a more favorable prognosis Anaplastic large T-cell lymphoma (ALCL) is a rare (1 per million) non-Hodgkin lymphoma that has been reported in women with and without breast prostheses. However, increasing case reports suggest an association with breast prostheses, although direct causation has not been established. ALCL associated with breast prostheses has malignant cells infiltrating the periprosthetic capsule or in the periprosthetic fluid collection. It is associated with both silicone- and saline-filled prostheses and seen in patients who have had prostheses for augmentation mammaplasty as well as breast reconstruction. Although the cytology is the same between ALCL associated with and without breast prostheses, ALCL that develops around prostheses tend to have an indolent clinical course and favorable prognosis when compared with systemic ALCL.

A 27-year-old woman is evaluated because of pain 2 weeks after undergoing subglandular augmentation mammaplasty. She has no history of fever, chills, or drainage. Physical examination discloses a painful, tender cord in the inframammary region of the left breast. Which of the following is the most appropriate next step in management? A) Administration of an antibiotic B) Administration of an anticoagulant C) Administration of an anti-inflammatory agent D) Duplex ultrasonography E) Removal of the implant

C) Administration of an anti-inflammatory agent Mondor disease of the breast is a benign, self-limiting thrombophlebitis of the inframammary veins. Clinically, Mondor disease usually occurs 2 to 3 weeks postoperatively as a painful, tender cord within the superficial veins of the thoracoepigastric system. Management is observation and includes the use of warm, moist dressings and anti-inflammatory agents for symptomatic relief. The use of anticoagulation, antibiotics, or steroids is not indicated. Implant removal is not indicated in the absence of infection. Duplex ultrasonography is not required for management.

A 25-year-old woman comes to the office because she is dissatisfied after undergoing breast augmentation mammaplasty for correction of tuberous breast deformities. Physical examination shows two parallel creases running transversely across the lower pole of each breast with inferior displacement of the implant. Which of the following best describes the position of the original inframammary fold in this patient? A) Above the superior and inferior transverse creases B) At the inferior transverse crease C) At the superior transverse crease D) Below the superior and inferior transverse creases

C) At the superior transverse crease A double-bubble breast deformity following breast augmentation mammaplasty is represented by the development of two parallel, curvilinear transverse lines in the lower pole of the breast. The native inframammary fold is disrupted and represented by the superior transverse line. The lower transverse line represents the lower limit of implant pocket dissection or the final position of implant descent. Predisposing anatomic factors for the development of a double-bubble deformity include tuberous breasts, constricted inframammary folds, or a short inframammary fold-to-nipple distance. Other factors that can increase the risk for the development of a double-bubble deformity include glandular ptosis, postpartum involution of the breasts, excessive implant size, and overdissection of the implant pocket. Correction of the double-bubble deformity may require conversion of the implant to a subglandular position, capsulorrhaphies, use of form-stable implants, or dermal grafts.

A 33-year-old woman with no family history of breast cancer undergoes bilateral augmentation mammaplasty with 300 mL of autologous fat per breast. Six months later, she has onset of pain in the right breast. Mammography shows linear clustered microcalcifications in the lower inner quadrant of the right breast, small lipid cysts bilaterally with scattered dystrophic rod-like calcifications in the upper outer quadrants bilaterally, and heterogeneity of the pectoral muscles. Which of the following is the most appropriate next step in management? A) Baseline mammography between ages 35 and 40 and yearly thereafter B) Core needle biopsy of the bilateral upper outer quadrants C) Core needle biopsy of the right lower inner quadrant D) Repeat mammography at 6 months and 12 months E) Repeat mammography in 1 year

C) Core needle biopsy of the right lower inner quadrant Augmentation mammaplasty with autologous fat transfer has become an increasingly popular option for patients desiring modest volumetric improvement. Despite its popularity, there is still some concern regarding its safety and efficacy. ASPS offered guidelines on fat grafting for reconstructive procedures of the breast in 2009. However, caution is recommended in the setting of cosmetic procedures because the impact on radiologic changes in follow-up is still uncertain to date. Fat necrosis is a nonspecific histologic finding most commonly resulting from surgery, trauma, or radiation therapy. It is common after fat transfer procedures, though often is clinically occult, and detected through follow-up mammography. The mammographic images of fat necrosis range from lipid cysts to findings that are suspected for malignancy such as clustered microcalcifications or spiculated masses. The most frequent mammographic finding in the breast parenchyma after augmentation mammaplasty with fat transfer is bilateral scattered microcalcifications followed by radiolucent oil cysts with or without microcalcification. Microcalcifications represent an evolution in the mammographic appearance of fat necrosis and are usually not present in early postoperative screening, but rather are a relatively late finding that is present months to years after the inciting trauma. It is imperative that radiologists distinguish between benign and suspected microcalcifications in order to minimize the number of postoperative biopsies and frequent follow-up imaging. Although round, spherical, punctuate, and diffusely scattered calcifications are typical of benign processes, cluster, branching microcalcifications can be indicative of a malignant process and should be worked up. For this 33-year-old patient with no baseline mammography and a suspected lesion within 6 months of the procedure, routine or short-interval mammographic screening is not appropriate. A biopsy of the suspected area is required, and this patient should undergo a core needle biopsy of the clustered microcalcifications of the right breast, while the more benign-appearing calcifications within the upper outer quadrants can be observed.

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

C) Grade III 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.

A 55-year-old woman who underwent augmentation mammaplasty with retro-pectoral smooth saline implants 18 years ago comes to the office because she is dissatisfied with her breast shape. Physical examination shows glandular ptosis hanging off the implants. She has Grade I capsules. Which of the following is the most appropriate procedure to correct this patient's deformity? A) Implant exchange alone B) Implant exchange with capsulectomy C) Implant exchange with mastopexy D) Implant exchange with suture plication of the expanded inferior pocket E) Site change to subglandular placement

C) Implant exchange with mastopexy The described patient has a "snoopy nose deformity" or "waterfall breast deformity," with the ptotic breast hanging off of the implant. There is no pocket expansion. The implants have stayed in their original position while the native breast tissue has become ptotic with time and gravity. This is not superior malposition due to capsular contracture; both breasts are soft. Correction of this problem is best performed with an appropriately chosen form of mastopexy. In this case, replacement of the implants would also be performed because of their age. Implant exchange alone would not correct the ptotic breast. Capsulectomy is not indicated, since the breasts are soft, and no capsule is noted clinically. Similarly, suture plication of the pocket is not required, since the inframammary fold is in the correct position, and no second fold is seen. Site change would not correct the patient's grade III ptosis, but it may be used to correct this problem in cases without significant ptosis.

A 28-year-old woman comes to the office to discuss augmentation mammaplasty. She is interested in silicone implants, specifically highly cohesive gel shaped implants. Which of the following is the most likely result of increasing the cross-linking in these implants? A) Decreased risk of gel fracture B) Decreased risk of shell delamination C) Improved form stability D) Increased risk of folds E) Softer implants

C) Improved form stability Increasing the cross-linking in a highly cohesive gel shaped silicone implant improves form stability. This allows for the creation of shaped implant designs that persist despite position or external forces on the implant. The current, fifth-generation silicone breast implants derive their cohesiveness from the cross-linking of the silicone. Increasing the amount of cross-linking leads to an increase in cohesiveness and a firmer implant. This may lead to less rippling and folding because of resistance to collapse; however, recent MRI studies have shown folds and distortions are still possible. Increasing cohesiveness, however, does have some disadvantages with potential risks for gel fracture and delamination of the implant shell.

A 32-year-old woman is scheduled to undergo augmentation mammaplasty with highly cohesive, anatomically shaped, silicone-filled breast implants. She asks the surgeon about postoperative monitoring for implant rupture. This patient should be counseled that, according to FDA recommendations, postoperative monitoring for rupture most appropriately includes which of the following? A) Manual examination 3 years postoperatively, then annually thereafter B) MRI screening 2 years postoperatively, then every 3 years thereafter C) MRI screening 3 years postoperatively, then every 2 years thereafter D) Ultrasonography screening 2 years postoperatively, then every 3 years thereafter E) Ultrasonography screening 3 years postoperatively, then every 2 years thereafter

C) MRI screening 3 years postoperatively, then every 2 years thereafter Diagnosis of rupture is difficult by physical examination alone, which is why the majority of ruptures are silent. Subsequent MRI screening for silent rupture is recommended initially 3 years postoperatively, then every 2 years thereafter. Highly cohesive, anatomically shaped, silicone-filled breast implants combine the "gummy bear" silicone with an anatomical shape, in which inferior pole projection is higher than the superior pole projection. In studies of Allergan's Natrelle 410 breast implants (the "Pivotal Study," the 410 Swedish MRI study, and the 410 European MRI study) approximately 3 in 100 women had silent ruptures. Cohesive gel is still subject to rupture, because rupture occurs when the shell fails. In cohesive implants, however, as opposed to noncohesive implants, the rupture rarely becomes extracapsular.

A 53-year-old woman comes to the office for evaluation of breast asymmetry. Reduction of the left breast and augmentation of the right breast with implant and autologous fat transfer are planned. She is concerned about fat injection and cancer risk. Which of the following is the most appropriate response regarding mammographic changes after fat transfer? A) Calcifications warranting biopsy are more likely on the fat transfer side B) Calcifications warranting biopsy are more likely on the reduction side C) Masses requiring biopsy are more likely on the reduction side D) Scarring will be decreased on the reduction side E) There are no differences between mammographic findings in fat transfer and reduction

C) Masses requiring biopsy are more likely on the reduction side Fat transfer to the breast remains a controversial procedure. There are some concerns about the oncologic safety of fat transfer, and for this reason some authors do not recommend fat transfer in patients with a history of cancer. Another concern about fat transfer is the potential difficulty in screening for malignancy. Rubin, et al. compared mammographic changes after fat transfer with changes after reduction mammaplasty. In this blinded study, radiologists reviewed pre- and postoperative mammograms of patients who had undergone augmentation and fat transfer and reduction mammaplasty. In the reduction cohort, masses requiring biopsy and scarring were more common; other abnormalities, including oil cysts, benign calcifications, and calcifications requiring biopsy showed no differences between the groups.

A 22-year-old nulliparous woman is evaluated for improvement of breast shape and size. Examination shows bilateral hypoplastic breasts with constricted bases and herniation of breast parenchyma in the areolae. Tuberous breast deformity is diagnosed. Bilateral breast augmentation with smooth, round gel implants via periareolar incisions is planned. Which of the following maneuvers is most likely to decrease the risk for a "double-bubble" deformity? A) Decreasing the areolar diameter B) Lowering of the inframammary fold C) Parenchymal scoring D) Periareolar incision E) Subpectoral placement of the implant

C) Parenchymal scoring Common hallmarks of tuberous breast deformity include varying degrees of hypoplastic breast parenchyma, deficiencies of the inferior pole, herniation of the parenchyma in the areola, enlarged areolae, superior placement of the inframammary fold, and asymmetry. Surgical goals are to achieve symmetry, sufficient volume (especially in the hypoplastic areas), lowering of the inframammary fold, reduction of areolar tissue herniation, and correction of any ptosis. A double-bubble deformity can occur when the inframammary fold is not sufficiently obliterated. The risk for this is increased with superiorly displaced inframammary folds, as in tuberous breasts. Parenchymal scoring would both release any constricting bands to allow the lower pole tissue to spread over the implant as well as release the superiorly displaced inframammary fold. While decreasing the areolar diameter and lowering of the inframammary fold are goals for breast improvement, neither will treat a double-bubble deformity. A periareolar incision is often advocated in repair of tuberous breasts because of the ability to reduce the areola; it alone, however, will not prevent a double-bubble deformity. Subpectoral placement of implants increases the risk for double-bubble deformity while subglandular placement of implants decreases the risk. Many advocate a dual-plane approach to capitalize on increased upper pole coverage combined with the benefits of a subglandular relationship in the inferior pole.

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

C) Superficial branches of the internal mammary artery from the second interspace 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 36-year-old woman is evaluated because of spontaneous galactorrhea 6 days after undergoing augmentation mammaplasty. Which of the following factors most likely contributed to this outcome? A) Inframammary placement of the incision B) Subglandular versus dual-plane position of the device C) Surgical interruption of the intercostal nerves D) Use of silicone versus saline breast implants

C) Surgical interruption of the intercostal nerves Although no one knows exactly what leads to postoperative galactorrhea, it is observed to occur more often in parous women and theorized to occur due to a combination of factors which simulate suckling or change in the innervation of the chest wall and nipple-areola complex. This would include increased tissue pressure related to the implant placement and interruption of intercostal nerves. No relationship has been identified between incision placement (peri-areolar, inframammary, transaxillary, or even peri-thelial) and postoperative galactorrhea. Similarly no relationship has been identified between device positioning (dual-plane, subglandular, and submuscular) and postoperative galactorrhea. Again, no relationship has been observed in implant type, saline versus silicone, and postoperative galactorrhea.

A 49-year-old woman is scheduled to undergo subglandular augmentation mammaplasty with silicone prostheses. During the preoperative discussion, the patient asks about postoperative complications with silicone versus saline prostheses. Which of the following is a disadvantage of using silicone in this patient? A) Their rupture results in an obvious decrease in breast size B) They are more likely to result in invasive breast cancer C) They can obscure breast tissue on mammagraphy D) They may show more rippling

C) They can obscure breast tissue on mammagraphy Silicone prostheses are radiopaque on mammography. Therefore, when placed in the subglandular position, a small percentage of breast tissue is obscured on mammography. Breast prostheses made completely of or in part with silicone have not been shown to cause a delay in detection of breast cancer. Women with breast prostheses are not more likely to develop breast cancer. Women with breast prostheses who have developed breast cancer are not diagnosed at a more advanced stage and do not have a worse prognosis or survival when compared with women without prostheses. Silicone prostheses are less likely to show superior pole rippling when compared with saline prostheses. If a saline prosthesis ruptures, the saline tends to become absorbed by the body, resulting in an obvious decrease in breast size after a few days. When silicone prostheses rupture, the silicone may remain intracapsular. These ruptures may change the breast shape slightly but usually do not change the size and are often subclinical.

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

D ) Rippling 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.

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

D ) Pseudoptosis 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.

In grade II ptosis of the breast, which of the following best describes the position of the nipple? A) At the apex of the breast mound B) At the lowest contour of the breast C) At the transposed inframammary fold D) Between the inframammary fold and the lowest contour of the breast E) On the posterior aspect of the breast as it rests on the chest wall

D) Between the inframammary fold and the lowest contour of the breast The classic Regnault definition of breast ptosis classifications are as follows: Grade I: Nipple at the level of the inframammary fold Grade II: Nipple between the level of the inframammary fold and the lowest contour of the breast Grade III: Nipple at the lowest contour of the breast

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

D) Herniation of breast tissue into the nipple-areola complex 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 French woman, who underwent placement of Poly Implant Prothèse (PIP) gel implants in 2009, comes to the office for consultation because she had heard that the implants were filled with a nonmedical grade silicone. She reports that she has not had any problems with the implants, but would like to know the implications of retaining the implants and whether she should have them removed. This patient should be told that she is at increased risk for which of the following complications if she retains the implants? A) Breast cancer B) Cytotoxicity C) Heavy metal poisoning D) Implant rupture E) Siloxane poisoning

D) Implant rupture The final report, in conjunction with the Department of Health in Australia, has shown a 2 to 6 times increased rupture rate in Poly Implant Prothèse (PIP) implants, which is detectable within 5 years of implantation. Increased levels of siloxane have been detected, but are not considered a health risk. No organic impurities have been detected and platinum levels are decreased in PIP gel compared with medical grade silicone. There is no increased breast cancer risk and no evidence of cytotoxicity. In the light of the increased rupture rate and the nonmedical grade nature of PIP silicone gel, the following recommendations were made: all providers of breast implant surgery should contact any women who have or may have PIP implants, if they have not already done so, and offer them a specialist consultation and any appropriate investigation to determine if the implants are still intact; if the original provider is unable or unwilling to do this, a woman should seek referral through her general practitioner to an appropriate specialist; if there is any sign of rupture, she should be offered an explantation; if the implants still appear to be intact, she should be offered the opportunity to discuss with her specialist the best way forward; if, in the light of this advice a woman decides with her specialist that, in her individual circumstances, she wishes to have her implants removed, her health care provider should support her in carrying out this surgery. Where her original provider is unable or unwilling to help, the NHS will remove, but not normally replace, the implants; if a woman decides not to seek early explantation, she should be offered annual follow up in line with the advice issued by the specialty surgical associations in January 2012. Women who make this choice should be encouraged to consult their doctor if they notice any signs of tenderness or pain, or swollen lymph glands in or around their breasts or armpits, which may indicate a rupture. At the first signs of rupture, they should be offered removal of the implants.

In women with breast ptosis, which of the following is an advantage of performing combined one-stage augmentation mammaplasty with mastopexy compared with mastopexy alone? A) Better predictability of cosmetic outcome B) Decreased complication rates C) Decreased revision rates D) Improved upper pole projection E) Lower operative costs

D) Improved upper pole projection Early reports have raised concerns about the safety of combined augmentation mammaplasty with mastopexy surgeries. However, in patients who wish to correct their breast ptosis these two procedures are often combined to a one-stage surgery and can show favorable outcomes. Nevertheless, plastic surgeons advocate that these cases should only be performed by experienced physicians. Reasons are that the overall aesthetic results are harder to predict in one-stage augmentation/mastopexy procedures compared to mastopexy alone or even the two-stage augmentation mammaplasty followed by mastopexy. Both complication and revision rates are highest in the one-stage approach that combines augmentation mammaplasty with mastopexy. Longer operative time and the need for implants naturally increase operative costs. The advantage of the simultaneous insertion of implants is the improved superior pole projection that cannot be achieved by mastopexy alone.

A 35-year-old woman, gravida 2, para 2, seeks implant-based augmentation mammaplasty. She breastfed both her children. Which of the following is the most common complication of this procedure? A) Early implant rupture B) Hematoma C) Infection D) Lifetime need for reoperation E) Seroma

D) Lifetime need for reoperation Augmentation mammaplasty is known to have high rates of complications including reoperation. Infection, seroma, hematoma, and early implant rupture are rare in elective, cosmetic augmentation mammaplasty.

A 47-year-old woman who underwent bilateral augmentation mammaplasty with silicone implants to treat mammary hypoplasia 17 years ago is evaluated because of worsening pain, firmness, and distortion of her breasts. Which of the following diagnostic evaluations is most sensitive for evaluating this patient's silicone breast implants? A) Breast thermography B) CT scan C) Mammography D) MRI E) Ultrasonography

D) MRI MRI scan would be the most sensitive and specific method for detection of silent rupture of a silicone breast implant in this patient. Classic MRI findings indicating rupture include the linguini sign or the teardrop sign. Current FDA recommendations are to obtain MRI screening for silent rupture three years after placement of silicone implants and every two years after that. CT scanning can show findings similar to those seen with MRI, but CT involves ionizing radiation, which can be harmful. CT has not been proven to be as sensitive as MRI in evaluating silicone breast implant rupture. Ultrasonography is a less costly method of implant evaluation but this method is highly operator-dependent. In asymptomatic women, a subsequent MRI scan is generally needed to confirm a positive ultrasound screen. Mammography is indicated for screening for breast cancer but not for implant rupture. Breast thermography utilizes digital infrared imaging to evaluate metabolic activity and vascular circulation of the breast to look for suspicious signs of breast cancer. It is not effective in the evaluation of silicone breast implant rupture.

Which of the following is the most common cause of litigation in cosmetic breast surgery? A) Assault B) Failure to diagnose or treat an injury related to the procedure C) Lack of informed consent D) Negligence E) Retained surgical instrument

D) Negligence Plastic surgery faces one of the highest proportions of malpractice claims compared with other medical specialties. A number of studies have revealed that breast-related surgeries account for 37% of overall claims against plastic surgeons. The most common cause of action is negligence, related either to lack of appropriate knowledge or skill or to failing to meet the standard of care. The second most common cause of action is lack of informed consent. Lack of informed consent results from the failure of the physician to thoroughly discuss the risks associated with surgery and the options of alternative therapies. Other causes of action include failure to diagnose or treat injury related to the procedure, retained surgical materials, assault, and distortion of physician's credentials.

Which of the following cell types is most associated with the chronic inflammation that leads to breast implant-associated anaplastic large cell lymphoma? A) B-cells B) Monocytes C) Neutrophils D) Red blood cells E) T-cells

E) T-cells Evidence suggests that chronic inflammation is the stimulus responsible for the development of breast implant-associated anaplastic large cell lymphoma (ALCL) and T-cells are the predominant cell type responding to this antigenic stimulus. B-cells have been implicated in orthopedic implant lymphomas. The other cell types are involved in inflammation, but they are not associated with breast implant-associated ALCL.

A 48-year-old woman comes to the office because she is very unhappy with the appearance of her breasts following a bilateral mastopexy performed 1 year ago. Height is 5 ft 7 in (170 cm). BMI is 26 kg/m2. Which of the following findings on physical examination would be most difficult to correct? A) Asymmetrical breast size B) Dog ear of the inferior vertical scar C) Nipple to inframammary crease distance of 16 cm D) Nipple to sternal notch distance of 16 cm E) Widened circumareolar scar

D) Nipple to sternal notch distance of 16 cm A sternal notch to nipple distance of 16 cm represents a high-riding nipple. Revisional surgery for correction of a high-riding nipple is complex, and it is difficult to achieve a favorable result because of the surgeon's and patient's desire to avoid a scar extending superior to the nipple areola. Further, the paucity of excess skin between the nipple and clavicle limits the reconstructive options. Suggested strategies include direct reposition of the nipple-areola complex, expansion of the skin between the nipple and clavicle, and repositioning of the breast parenchyma and inframammary crease. Breast size asymmetry can be improved with either liposuction or revision mastopexy/reduction. The operation is usually performed using the previous incisions. A dog ear of the inferior vertical scar is easily revised with a small transverse scar within the inframammary crease. The majority of these early postoperative deformities will resolve without surgery. Recurrence of ptosis or an elongation of the nipple to inframammary crease distance occurs with all mastopexy operations. When performing secondary mastopexy, this can be improved with shortening the vertical scar with wedge resection at the inframammary crease. Knowledge of the location of the previous nipple areola pedicle is helpful in minimizing vascular complications. Widened circumareolar scars can be revised with excellent results. Utilizing a permanent suture around the areola helps control size of the areola and tension on the suture line.

A patient comes to the office 6 months after undergoing bilateral vertical mastopexy because she is dissatisfied with her postoperative appearance. Height is 5 ft 5 in (165 cm). Physical examination shows the distance from nipple to sternal notch is 16 cm bilaterally, and the distance from nipple to inframammary fold is 14 cm bilaterally. Which of the following is the most appropriate next step in management? A) Conversion to free nipple grafts B) Placement of a dual-plane breast implant C) Placement of a subglandular breast implant D) Resection of excess skin at the level of the inframammary fold E) Reassurance, massage, and observation

D) Resection of excess skin at the level of the inframammary fold This case illustrates superior nipple malposition. The distance from nipple to inframammary (IMF) fold of 14 cm is much too long. The correct answer is to resect the lower pole skin at the IMF in order to move the nipple down. This would create a "T" scar and improve nipple position. Vertical mastopexies and reduction mammaplasties have a learning curve and much of this is predicting the nipple position postoperatively. The nipple should be designed lower on the breast than is done during marking a Wise pattern. At 6 months, it is unlikely the nipple position will change dramatically, so observation is not recommended. Addition of an implant will not help the nipple position. Conversion to free nipple grafts, while possible, will not lead to an aesthetic scar pattern.

A 58-year-old woman undergoes removal of round 280-cc silicone gel implants she has had for over 30 years. New silicone gel implants measuring 10 cm in width by 12 cm in height with a 5-cm projection are placed. Compared with her original gel implants, the new implants are more likely to have a higher rate of which of the following complications? A) Contracture B) Infection C) Rippling D) Rotation E) Rupture

D) Rotation Breast implant technology has evolved greatly since implants were introduced in the 1960s. Increased cross-linking of silicone polymers (polydimethylsiloxanes) results in a more stable, cohesive form and closer shell-gel interactions. Advantages of these more "form-stable" implants include lower rates of rippling and rupture. They allow for the creation of shaped implants that offer clear advantages for certain patients, such as those seeking a natural upper pole shape transition, and those with wider or taller breast shapes. The biggest drawback of shaped implants is the need to place them in a precise surgical pocket lest they rotate, causing deformity and potentially requiring reoperation. As long as surgeons follow sound surgical principles of dissecting an appropriate pocket limited to the approximate width of the implant, malrotation rates are low, typically in the 1.5% range. In one study, half of patients with implant rotation improved with manual repositioning and taping for 3 to 6 weeks, while the other half required reoperation. Infection rates do not vary among implant types. Shaped implants have textured shells, which have been shown to have lower rates of capsule contracture, particularly in the subglandular position. Implant rupture rates are also lower in new generation implants, in the 0.7% per year range. Visible rippling rates are more common in thinner consistency implants, such as saline and older silicone devices.

A 35-year-old woman comes to the office for consultation because she is dissatisfied with the appearance of her "deflated" and "saggy" breasts. Augmentation/mastopexy is planned. Compared with placement of the implant in the subglandular position, placement of the implant in the subpectoral space will preserve blood supply to the breast tissue and skin through which of the following arteries? A) Internal thoracic B) Lateral thoracic C) Superficial superior epigastric D) Thoracoacromial E) Thoracodorsal

D) Thoracoacromial The perfusion of the nipple-areola complex is a major concern during breast procedures involving periareolar and intraparenchymal incisions. The nipple-areola complex has a very rich and overlapping perfusion through multiple sources. This fact allows the design of various pedicles to carry the nipple and areola with different techniques. The blood supply through the internal thoracic vessels reaches the breast, nipple, and areola through the intercostal perforators, which may be divided during both subpectoral and subglandular implant placement. The location of the implant deep or superficial to the pectoralis muscle will not change the perfusion through the superficial epigastric vessels. The same is true for the blood supply through the lateral thoracic vessels. However, the flow through the thoracoacromial vessels to the breast parenchyma will be preserved by placement of the implant deep to the pectoralis muscle. Creation of a subglandular pocket above the muscle will interrupt the collaterals from the thoracoacromial vessels through the muscle to the parenchyma. The thoracodorsal artery is not a major source of blood supply to the breast and the position of the implant will not affect it.

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

D)Purse-string suture 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

D)Thoracoacromial 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 36-year-old woman, gravida 3, para 3, comes to the physician because she desires larger breasts. She has breast-fed three children. Physical examination shows grade 3 ptosis and loss of superior pole volume. The distance from nipple to sternal notch is 26 cm. Result of upper pole pinch test is 1.5 cm. A dual-plane augmentation/mastopexy is planned. Which of the following is the strongest indicator for subpectoral placement of the implant in this patient? A) Concurrent mastopexy B) Grade 3 ptosis C) Loss of superior pole volume D) Nipple to sternal notch distance of 26 cm E) Pinch test result of 1.5 cm

E) Pinch test result of 1.5 cm A dual-plane approach is subpectoral in the superior pole and subglandular in the inferior pole. This is to afford more subcutaneous coverage in the superior pole. Tebbetts recommends pinching the skin and subcutaneous tissues of the superior pole for a "pinch test." For thickness less than 2 cm, he recommends a dual-plane placement for adequate soft tissue coverage. This is not affected by the grade of ptosis, need for mastopexy, history of loss of superior pole volume, or nipple to notch distance.

A 35-year-old woman comes for consultation regarding breast prosthesis removal because she is concerned about her risk of cancer. Specifically, she has read about anaplastic large cell lymphoma in women with breast prostheses. She underwent augmentation mammaplasty with saline breast prostheses 5 years ago. Physical examination shows absence of contracture and satisfactory position. Which of the following is the most appropriate next step in management? A) Complete blood cell count B) Evaluation by a hematologist C) MRI of the breasts D) Prosthesis removal E) Reassurance

E) Reassurance The US Food and Drug Administration (FDA) searched its adverse event reporting systems for reports received between January 1, 1995 and December 1, 2010, including information submitted by manufacturers as part of their required post-approval studies. This search identified 17 reports of possible anaplastic large cell lymphoma (ALCL) in women with breast prostheses. Although ALCL is extremely rare, the FDA believes that women with breast prostheses may have a very small but increased risk of developing this disease in the scar capsule adjacent to the prosthesis. Based on available information, it is not possible to confirm with statistical certainty that breast protheses cause ALCL. Currently, it is not possible to identify a type of prosthesis (silicone gel versus saline) or a reason for implantation (reconstruction versus aesthetic augmentation) associated with a smaller or greater risk. When ALCL occurs, it has been most often identified in patients undergoing prosthesis revision procedures for late-onset, persistent seroma. Because it is so rare and most often identified in patients with late onset of symptoms such as pain, lumps, swelling, or asymmetry, it is unlikely that increased screening of asymptomatic patients would change their clinical outcomes. The FDA does not recommend prophylactic breast prosthesis removal in patients without symptoms or other abnormalities. A patient with suspected ALCL should be referred to an appropriate specialist for evaluation. When testing for ALCL, fresh seroma fluid and representative portions of the capsule should be collected and sent for pathology tests to rule out ALCL. Diagnostic evaluation should include cytologic evaluation of seroma fluid with Wright-Giemsa-stained smears and cell block immunohistochemistry testing for cluster of differentiation and anaplastic lymphoma kinase markers. Any confirmed cases of ALCL in women with breast prostheses must be reported to the FDA.

A 26-year-old healthy woman comes to the office for consultation because she has constant pain 1 year after undergoing augmentation mammaplasty by another surgeon. She reports that he "botched" her surgery and that she is considering taking legal action against him. On physical examination, the breasts are quite firm and mildly tender. The relatively immobile subglandular implants are high on the chest wall. There are no overlying skin changes. Which of the following is the most appropriate response by the surgeon in this scenario? A) Decline to establish care B) Follow-up visit in one year C) Perform a diagnostic intercostal nerve block D) Prescribe a course of oral corticosteroids E) Recommend surgical intervention

E) Recommend surgical intervention This patient has developed Baker grade IV capsular contracture as evidenced by hard, painful breast implants that are malpositioned. This is a known complication of augmentation mammaplasty, and the patient should be informed that it is treatable with another surgery. It would be reassuring to the patient to hear that it is a known post-operative complication that happens not uncommonly, and that it is unlikely the other surgeon directly did anything to cause this. Thoughtful analysis and contextualization are helpful in high-tension consultations such as these. Providing the patient with a malpractice attorney's contact information may be what she thinks she wants, but diffusing the situation is best for all involved. Dismissing the patient's concerns outright without diagnosing her and suggesting a course of treatment would not be helpful. The new surgeon may even take it a step further by offering to speak with her previous surgeon to discuss the patient's concerns and the findings seen during consultation. The patient may refuse to allow this, and she may have lost faith in her other surgeon, but at least offering to speak with the other surgeon is prudent and may restore the relationship between this patient and her surgeon. A pain management specialist and physical therapy may help somewhat with symptoms, but her problem ultimately requires and should respond well to a surgical solution.

Breast implant-associated anaplastic large cell lymphoma is most closely associated with which of the following implant characteristics? A) High-profile dimensions B) Saline filling C) Silicone gel filling D) Smooth shell E) Textured shell

E) Textured shell The overwhelming majority of reported cases of breast implant-associated anaplastic large cell lymphoma (BIA-ALCL) have been associated with textured surface implants. Anaplastic large cell lymphoma in association with breast implants is a rare occurrence; however, when it does appear, the course is usually less aggressive with a better prognosis than when it is unrelated to breast implants. Recent studies suggest that the breast implant shell causes a chronic T-cell stimulation. This reaction is thought to be caused by an interaction of textured surface characteristics and associated biofilm. BIA-ALCL associated with smooth shell implants has occurred; however, it is disproportionately rare. ALCL is seen with both silicone- and saline-filled implants. These numbers are highly influenced by the specific popularity of each implant. Specific implant dimensions, be it projection or width, are not uniquely associated with ALCL.

A 39-year-old woman comes to the office with a 6-month history of progressive firmness and superior fullness of the left breast. History includes bilateral augmentation mammaplasty with textured saline implants placed in a submuscular dual-plane pocket 15 years ago. On physical examination, the left breast appears larger and firmer with more upper pole fullness in comparison with the right breast. Which of the following is the most appropriate next step? A) Capsulectomy and pocket change B) Mammography C) 3-Month trial of montelukast (Singulair) D) MRI E) Ultrasonography

E) Ultrasonography Breast implant patients who present with late-onset enlargement of one of their breasts require evaluation for breast implant-associated anaplastic large cell lymphoma (BIA-ALCL). This disease usually presents with spontaneous onset of peri-prosthetic fluid. A late-onset seroma is usually accepted as occurring 1 year after surgery; however, they have presented as early as 4 months. It is often difficult to determine if late-onset firmness of the implant is secondary to fluid, capsular contracture, or both. The initial workup should begin with an ultrasound to evaluate for peri-prosthetic fluid or capsular mass. If fluid is present, it should be sent for cytology, flow cytometry with immunohistochemistry looking for expression of T-cell CD30 cell surface protein. BIA-ALCL is overwhelmingly associated with textured implants. It is important to remember that BIA-ALCL is extremely rare and that most patients presenting with a late seroma will not have lymphoma, but will have peri-prosthetic fluid from the textured surface pulling away from the capsule and forming a double capsule. The treatment for localized BIA-ALCL is bilateral total capsulectomy and explantation. Treatment for the more likely double capsule or capsule contracture is capsulectomy and pocket change; however, surgery is not indicated until the diagnosis is made. Montelukast is a leukotriene antagonist that can inhibit the inflammatory cascade thought to be involved with capsular contracture. It seems to be more useful in patients with capsular contracture less than grade III. There is no consensus on its use or effectiveness. The sensitivity and specificity of ultrasound for detecting a seroma has been equal or better than MRI or 3D mammography. After diagnosis of ALCL, MRI and PET scanning may be indicated. If the implants were silicone gel, MRI would be indicated to evaluate for implant rupture; however, ultrasound would still be recommended for seroma evaluation and aspiration.

A 28-year-old woman is evaluated for micromastia. During consultation, she reports that her best friend underwent breast augmentation that was complicated by painful capsular contracture. Which of the following measures is most likely to prevent this complication in this patient? A) Initiation of implant massage on postoperative day 5 B) Placement of a closed suction drain for prevention of postoperative hematoma C) Use of a surgical support bra postoperatively for 2 weeks D) Use of a subglandular, smooth, round implant via periareolar incision E) Use of a subpectoral, textured implant via inframammary incision

E) Use of a subpectoral, textured implant via inframammary incision Capsular contracture occurs when there is fibrosis of the peri-implant capsule. The severity is typically described by the Baker Grade classification. Grade 1: the breast is soft and appears normal in size and shape Grade 2: the breast is a little firm and appears normal Grade 3: the breast is firm and appears abnormal Grade 4: the breast is firm, appears abnormal, and is painful Studies have shown a decreased relative risk for Baker grade 3-4 capsular contracture in primary breast augmentation associated with inframammary fold incision, textured implants, and subpectoral placement. The relative risk for capsular contracture was increased with periareolar or axillary incision, smooth implants, and subglandular placement. There is no evidence that wearing a support bra or implant massage will decrease the risk for capsular contracture. While hematoma is linked to capsular contracture, the presence of a drain does not prevent hematoma.

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

E) Widening of the areola 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 25-year-old woman is considering augmentation mammaplasty with silicone prostheses. The patient asks about the associated risks of developing connective tissue disease. Which of the following risk assessments is most accurate in this patient? A)Increased risk of extracapsular leak only B)Increased risk of intra- and extracapsular leak C)Increased risk only if the silicone migrates to the lymph node D)Increased risk only in the pre-1990 prostheses E)No increased risk

E)No increased risk Concern regarding an association between silicone breast prostheses and connective tissue disease was raised in the 1980s and early 1990s, eventually leading to the US Food and Drug Administration (FDA) moratorium of the use of silicone breast prostheses in augmentation mammaplasty. Since then, multiple cohort studies and case control studies in Europe and North America have failed to determine a causative association between silicone breast prostheses and any traditional or atypical connective tissue diseases.

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

E)Total capsulectomy 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.

An 18-year-old woman comes to the office for evaluation of her breasts. Photographs of the patient are shown (Tuberous breast deformity). Which of the following statements most accurately describes the anatomy of this patient's breasts? A) The areola is normal size although the breast is small B) The breast tissue is uniformly distributed throughout the breast pocket C) The inframammary fold is elevated D) The skin envelope has greater laxity than in a normal breast E) The underlying musculature is underdeveloped

The tuberous breast deformity results in a protruding, oblong shape that resembles a tuberous root plant (Latin derivation tuber = to swell). The features noted in the tuberous breast deformity include a constricted breast base, decreased breast parenchyma, abnormal elevation of the inframammary fold, a decreased skin envelope, and herniation of the breast parenchyma through the central breast and into the areola. The areola is large and lacks firm underlying structure, thus allowing the breast tissue to protrude through this path of least resistance. The deformity is also often referred to as a tubular breast, constricted breast, doughnut breast, nipple breast, breast with narrow base, dome nipple, and snoopy dog breast. The overall etiologic factors leading to the full expression of the constricted breast deformity are still largely unknown and likely involve a delicate balance of anatomic and endocrinologic forces. A constricting fibrous ring at the level of the areola periphery, representing probably a thickening of the superficial fascia coupled with the normally absent fascial layer in the NAC, has been proposed as a likely cause. The ring is composed of dense fibrous tissue made of large concentrations of collagen and elastic fibers arranged longitudinally. It is usually denser at the lower part of the breast and does not allow the developing breast parenchyma to expand during puberty. It has been suggested that a thickening of the superficial fascia combined with the absence of a superficial fascial layer under the NAC is the underlying anatomic/histopathologic cause of the deformity. The cause of the thickened fascia is unknown, although at least one study by Klinger, Caviggioli, et al. demonstrated altered collagen in both disposition and quantity. The same study excluded amyloid deposition as a component of the fibrosis. The areola in the tuberous breast still contains the normal muscular structures that result in areolar changes with stimulation and temperature changes, although the tissue beneath the areola may be thinned.