Which of the following surgical procedures would most effectively re-establish aesthetic breast contour?

(A) Delayed mastopexy
(B) Inframammary fold wedge excision
(C) Periareolar mastopexy
(D) Modified Kiel (vertical) mastopexy
(E) Wise pattern mastopexy

The correct response is Option A.

In this patient who has just undergone explantation of ruptured bilateral breast implants, the aesthetic contour of the breast will be best re-established with a mastopexy procedure that is delayed for at least three months following the explantation. Indications for this procedure include severe ptosis requiring nipple elevation of 4 cm, a breast mound smaller than 4 cm, and a significant history of smoking. Because this patient has many risk factors and moderate ptosis, requiring 2 cm to 4 cm of nipple repositioning, a two-stage procedure is recommended to reduce the risk for potential complications, including skin loss or compromise of the nipple-areolar complex. Simultaneous breast contouring procedures should be avoided in these patients. The initial stage involves explantation and capsulectomy using an inframammary approach; elective mastopexy is then performed three months later.

Inframammary fold wedge excision is recommended for patients with pseudoptosis. This is defined as adequate breast volume and positioning of the nipple above the inframammary crease with a nipple-to-inframammary crease distance of greater than 6 cm. The wedge excision technique involves transposition of the inferior dermal parenchymal flap in order to increase breast projection.

For patients who have grade I ptosis, a tension-free periareolar mastopexy can be performed to reposition the nipple if it lies more than 2 cm below the inframammary fold and has a diameter of less than 50 mm. In contrast, if the diameter is greater than 50 mm and more than 2 cm of repositioning is required, a modified Kiel (vertical) mastopexy is recommended instead. Patients with moderate grade II ptosis who require repositioning of 2 cm to 4 cm should undergo Wise pattern or a similar type of mastopexy.

References
1. Rohrich RJ, Beran SJ, Restifo RJ, et al. Aesthetic management of the breasts following explantation: evaluation and mastopexy options. Plast Reconstr Surg. 1998;101:827-837.
2. Spear SL, Little JW. Reduction mammoplasty and mastopexy. In: Aston SJ, Beasley RW, Thorne CH, eds. Grabb & Smith's Plastic Surgery. 5th ed. Philadelphia, Pa: Lippincott-Raven; 1997:742-751.

PHOTO

Which of the following is the most accurate statement regarding the patient who has the findings shown in the above photograph?

(A) This condition has been shown to initially develop at or around the third week of gestation
(B) This condition is typically familial
(C) Contralateral hand anomalies are associated
(D) Hypoplasia of the pectoralis major muscle is associated
(E) This patient is at increased risk for the development of carcinoma of the breast

The correct response is Option D.

This patient has Poland's syndrome, a condition whose manifestations include unilateral aplasia or hypoplasia of the pectoralis major muscle and ipsilateral hand anomalies. Chest wall anomalies are also seen unilaterally and can include axillary banding, aplasia or hypoplasia of the breast or nipple, hypoplasia of the scapula or ribs, and anomalies of the shoulder girdle.

Poland's syndrome typically occurs sporadically and its etiology is not fully understood; however, one theory implicates a vascular event occurring at or around the seventh week of gestation, when the developing hand lies close to the chest wall.

There is no reported link between Poland's syndrome and carcinoma of the breast.

References
1. Samuels TH, Haider MA, Kirkbride P. Poland's syndrome: a mammographic presentation. Am J Roentgenol. 1996;166:347-348.
2. Van Hoest AE. Congenital disorders of the hand and upper extremity. Pediatr Clin North Am. 1996;43:1123.
3. Wilson MR, Louis DS, Stevenson TR. Poland's syndrome: variable expression and associated anomalies. J Hand Surg. 1988;13A: 880-882.

Which of the following findings are consistent with tuberous breast syndrome?

(A) Deficiency of the skin envelope, a decrease in vertical breast height, breast hypoplasia, and absence of the pectoralis major muscle
(B) Deficiency of the skin envelope, a decrease in vertical breast height, breast hypoplasia, and areolar hypertrophy
(C) Deficiency of the skin envelope, elongation of vertical breast height, breast hypertrophy, and absence of the pectoralis major muscle
(D) Redundancy of the skin envelope, a decrease in vertical breast height, breast hyperplasia, and absence of the pectoralis major muscle
(E) Redundancy of the skin envelope, elongation of vertical breast height, breast hyperplasia, and areolar hypertrophy

The correct response is Option B.

Tuberous breast syndrome, also referred to as tubular breast syndrome or constricted breast syndrome, is comprised of a broad spectrum of features. Patients with tuberous breast syndrome may have any or all of several findings. These can include a deficiency in the skin envelope that can involve only one quadrant or can lead to severe constriction, a decrease in the overall vertical height from the top of the breast to the inframammary fold, hypertrophy of the areola, which is believed to compensate for constriction at the base of the breast, and a true deficit of breast tissue, particularly at the area of skin deficiency. After the skin is released surgically, volume must be added to create a normal-appearing breast.

Absence of the pectoralis major muscle is a feature of Poland's syndrome.

References
1. Von Heimburg HD, Exner K, Kruft S, et al. The tuberous breast deformity: classification and treatment. Br J Plast Surg. 1996;49:339-345.
2. Dinner MI, Dowden RV. The tubular/tuberous breast syndrome. Ann Plast Surg. 1987;19:414-419.

A 45-year-old woman who underwent bilateral augmentation mammaplasty with silicone gel implants 20 years ago has developed capsular contracture involving one of her implants. She is concerned about the integrity of the implants. Ultrasonography suggests intracapsular rupture of the implant.

Which of the following is the most appropriate next step in management?

(A) Observation
(B) Level-two ultrasonography
(C) Mammography
(D) MRI
(E) Surgery

The correct response is Option E.

This patient who has probable intracapsular rupture of one of her 20-year-old silicone gel implants requires surgery to remove the ruptured implant and periprosthetic capsule. Test characteristics (sensitivity and specificity) and implant rupture prevalence have been used to calculate the probability of rupture for various patient scenarios. In asymptomatic patients, the pretest rupture prevalence is estimated at 6.5%. Ultrasonography should be used as an initial diagnostic test because of its relatively low cost. If screening ultrasonography shows no rupture, the probability of rupture drops to 2.2%. No further work-up is necessary. If ultrasonography suggests rupture, the relatively low probability (37.8%) of true rupture requires a confirmatory test using MRI.

In symptomatic patients (ie, patients who have breast asymmetry or capsular contracture), the high prevalence of rupture markedly raises the probability of rupture after positive findings on ultrasonography. In symptomatic patients whose implants are no more than ten years old, the prevalence of rupture is estimated to be 31%. Positive ultrasonography increases the probability of true rupture to 79.7%, and this probability is increased to 97.5% if a follow-up MRI shows rupture. In this woman and other symptomatic patients whose implants are more than ten years old, the high probability of true rupture (94%) after positive findings on ultrasonography obviates the need for any further diagnostic testing such as MRI.

Observation is inadequate because implants that are known or suspected to be ruptured should be removed. Mammography is recommended for screening of benign and malignant diseases. However, evaluation of implant status by routine mammography is limited, particularly in cases of intracapsular rupture. Not all of the implant and surrounding breast tissue can be visualized, and patients with severe capsular contracture and painful breasts may not be able to undergo the compressive technique required to execute the study. Only when the silicone has migrated away from the fibrous capsule (extracapsular rupture) can mammography offer accurate diagnosis.

Level-two ultrasonography is a diagnostic maneuver used to evaluate a fetus in the obstetrical setting.

References
1. Beekman WH, van Straalen WR, Hage JJ, et al. Imaging signs and radiologists' jargon of ruptured breast implants. Plast Reconstr Surg. 1998;102:1281-1289.
2. Chung KC, Greenfield ML, Walters M. Decision-analysis methodology in the work-up of women with suspected silicone breast implant rupture. Plast Reconstr Surg. 1998;102:1281-1289.

Which of the following is most characteristic of an in vivo subglandular breast implant that was placed 10 years ago?

(A) Changes in the implant shell that may interfere with mammography
(B) Easier palpability resulting from increased stiffness of the implant shell
(C) Increased potential for the development of immune-related disorders
(D) Invasion of the implant shell by surrounding periprosthetic capsular tissue
(E) Loss of biomechanical shell strength when compared with preimplantation levels

The correct response is Option E.

In a patient who underwent in vivo subglandular breast implantation 10 years ago, a loss of biomechanical strength of the implant shell, when compared with preimplantation levels, is most likely to be identified. Because the implant shell is composed of a vulcanized silicone elastomer, its mechanical strength has been shown to weaken over time following implantation. This weakening, which may result from various factors such as lipid infiltration of the silicone elastomer, has been linked to aging and rupture of the implant.

Any changes that occur in the implant shell will not interfere with mammography or with the palpability of the implant. However, other complications, such as capsular contracture, will affect the findings seen on mammography. Therefore, it is important for patients who have breast implants to undergo mammographic evaluation at specialized centers experienced at obtaining mammograms using the displacement (Eklund) technique, which maximizes visualization of the breast parenchyma.

The stiffness of the implant shell does not change with time. In the same way, the incidence of immune-related disorders remains steady over the duration of implantation, at one in 40,000 patients.

Infiltration of the implant shell by the surrounding capsule has not been demonstrated or implicated in the rupture of aging implants.

References
1. Adams WP Jr, Robinson JB Jr, Rohrich RJ. Lipid infiltration as a possible biologic cause of silicone gel breast implant aging. Plast Reconstr Surg. 1998;101:64.
2. Greenwald DP, Randolph M, May JW Jr. Mechanical analysis of explanted silicone breast implants. Plast Reconstr Surg. 1996;98:269.
3. Phillips JW, de Camara DL, Lockwood MD, et al. Strength of silicone breast implants. Plast Reconstr Surg. 1996;97:1215.