In a patient with breast implants, each of the following has been shown to interfere with screening mammography EXCEPT

(A) Baker III capsular contracture
(B) implant location
(C) implant size
(D) native breast volume

The correct response is Option C.

Several factors have been shown to affect the findings on mammography in women with breast implants. The positioning of the implant and the degree of associated capsular contracture have been known to influence the quantity of breast tissue that can be visualized. In addition, one study showed an increase in the amount of tissue that can be visualized postoperatively in a subset of women with small native breast volume. Therefore, it is important for patients who have breast implants to undergo mammographic evaluation at specialized centers experienced at obtaining mammograms using either compression or displacement (Eklund) techniques, which maximize visualization of the breast parenchyma.

The size of the implant has not been shown to affect the amount of breast tissue that can be visualized on mammography.

References
1. Eklund GW, Busby RC, Miller SH, et al. Improved imaging of the augmented breast. Am J Radiol. 1988;151:469-473.
2. Handel N, Silverstein MJ, Gamagami P, et al. Factors affecting mammographic visualization of the breast after augmentation mammaplasty. JAMA. 1993;269:987-988.
3. Silverstein MJ, Handel N, Gamagami P, et al. Mammographic measurements before and after augmentation mammaplasty. Plast Reconstr Surg. 1990;86:1126-1130.

In order to make the diagnosis of Poland's syndrome, which of the following findings must be present?

(A) Absence of the nipple
(B) Absence of the sternal head of the pectoralis major muscle
(C) Brachysyndactyly
(D) Hypoplasia of the latissimus dorsi muscle
(E) Skeletal abnormalities of the chest wall
The correct response is Option B.

All patients diagnosed with Poland's syndrome, a congenital abnormality associated with unilateral findings, have absence of the sternal head of the pectoralis major muscle on the affected side. Some patients with Poland's syndrome have absence of the entire muscle, hypoplasia or absence of the latissimus dorsi or serratus muscles, and/or complete absence of the breast. Other chest wall anomalies also occur unilaterally and can include axillary banding, aplasia or hypoplasia of the nipple, and hypoplasia of the scapula or ribs. Brachysyndactyly of the ipsilateral upper extremity is seen in some patients.

References
1. Garcia VF, Seyfer AE, Graeber GM. Reconstruction of congenital chest-wall deformities. Surg Clin North Am. 1989;69:1103-1118.
2. Hester TR Jr, Bostwick J III. Poland's syndrome: correction with latissimus muscle transposition. Plast Reconstr Surg. 1982;69:226-233.

A 24-year-old woman has worsening pain and swelling of the right breast 24 hours after undergoing subpectoral augmentation mammaplasty with smooth, round saline-filled implants. On physical examination, the right breast appears significantly larger and is more firm to palpation than the left breast. There are no signs of erythema or ecchymosis.

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

(A) Observation
(B) Application of an external compression bandage
(C) Percutaneous needle aspiration
(D) Ultrasound-guided drainage
(E) Surgical exploration

The correct response is Option E.

This patient has findings consistent with a hematoma, which has been shown to develop in 1% to 3% of patients who have undergone breast augmentation. Hematomas can be seen as late as 14 days postoperatively. The most appropriate next step in management is prompt surgical exploration to evacuate the hematoma and ensure careful hemostasis. The implant can be replaced if there is no evidence of infection; the contralateral implant should only be removed if it is affected.

Observation or application of an external compression bandage will only delay the diagnosis and increase the risk for infection or development of capsular contracture. Percutaneous needle aspiration or ultrasound-guided drainage will not completely evacuate the hematoma and will increase the risk for implant perforation.

References
1. Courtiss EH, Goldwyn RM, Anastasi GW. The fate of breast implants with infections around them. Plast Reconstr Surg. 1979;63:812.
2. Maxwell GP, Clugston PA. Management of complications following augmentation mammoplasty. In: Georgiade GS, Riefkohl R, Levin LS, eds. Textbook of Plastic, Maxillofacial and Reconstructive Surgery. Baltimore, Md: Williams & Wilkins; 1997:736.

Prior to breast augmentation, management of milky discharge in a regularly menstruating woman should include which of the following?

(A) Observation
(B) Massage
(C) Measurement of serum prolactin level
(D) Administration of antibiotics
(E) Ovarian biopsy

The correct response is Option C.

Although breast discharge is rare in regularly menstruating women who have never been pregnant, it has been shown to occur in 25% of women who have been pregnant in the past. Complete evaluation of galactorrhea should include measurement of the serum level of prolactin (a lactogenic hormone required for milk production), thyroid function studies to rule out hypothyroidism, and a history of all medications, as tricyclic antidepressants and fluoxetine have been shown to contribute to breast discharge. Women who have increased serum prolactin levels should then undergo MRI evaluation to rule of the possibility of pituitary tumor. According to a series of four studies involving more than 500 patients with galactorrhea, a pituitary tumor was the underlying cause in 25%; in contrast, 50% of those studied had idiopathic causes. Appropriate management of idiopathic galactorrhea includes administration of bromocriptine to suppress the release of prolactin.

Observation is inadequate management because of the risk for pituitary tumor in these patients. Breast massage is not appropriate and will instead maintain or even initiate galactorrhea in women with prior pregnancies. Because galactorrhea is not associated with infection, antibiotics should not be administered; however, if the discharge is bloody or has brown or green discoloration, the patient should be evaluated for possible infection or tumor. Ovarian biopsy is only indicated if evaluation shows ovarian pathology.

References
1. Braunwald E, Fauci AS, Kasper DL, et al, eds. Harrison's Principles of Internal Medicine. 15th ed. New York, NY: McGraw-Hill, Inc; 2001;2:2036-2037.
2. Friedman S, Goldfien A. Breast secretions in normal women. Am J Obstet Gynecol. 1969;104:846.

Prior to breast augmentation, management of milky discharge in a regularly menstruating woman should include which of the following?

(A) Observation
(B) Massage
(C) Measurement of serum prolactin level
(D) Administration of antibiotics
(E) Ovarian biopsy

The correct response is Option C.

Although breast discharge is rare in regularly menstruating women who have never been pregnant, it has been shown to occur in 25% of women who have been pregnant in the past. Complete evaluation of galactorrhea should include measurement of the serum level of prolactin (a lactogenic hormone required for milk production), thyroid function studies to rule out hypothyroidism, and a history of all medications, as tricyclic antidepressants and fluoxetine have been shown to contribute to breast discharge. Women who have increased serum prolactin levels should then undergo MRI evaluation to rule of the possibility of pituitary tumor. According to a series of four studies involving more than 500 patients with galactorrhea, a pituitary tumor was the underlying cause in 25%; in contrast, 50% of those studied had idiopathic causes. Appropriate management of idiopathic galactorrhea includes administration of bromocriptine to suppress the release of prolactin.

Observation is inadequate management because of the risk for pituitary tumor in these patients. Breast massage is not appropriate and will instead maintain or even initiate galactorrhea in women with prior pregnancies. Because galactorrhea is not associated with infection, antibiotics should not be administered; however, if the discharge is bloody or has brown or green discoloration, the patient should be evaluated for possible infection or tumor. Ovarian biopsy is only indicated if evaluation shows ovarian pathology.

References
1. Braunwald E, Fauci AS, Kasper DL, et al, eds. Harrison's Principles of Internal Medicine. 15th ed. New York, NY: McGraw-Hill, Inc; 2001;2:2036-2037.
2. Friedman S, Goldfien A. Breast secretions in normal women. Am J Obstet Gynecol. 1969;104:846.

Which of the following is the most common complication of periareolar mastopexy?

(A) Dehiscence
(B) Excessive breast projection
(C) Nipple discharge
(D) Recurrent ptosis
(E) Widening of the areola

The correct response is Option E.

Widening of the areola is the most common complication following periareolar mastopexy. Techniques developed to minimize the occurrence of areolar dilation include the use of nonresorbable purse-string sutures and creation of an excessively small areola at the time of surgery to compensate for postoperative widening.

Less common complications include dehiscence and recurrent ptosis. Excessive projection is rarely seen with periareolar mastopexy; flattened or globular breast shapes are more commonly reported. Nipple discharge is not associated with mastopexy.

References
1. Atiyeh BS, Hashim HA, El-Douaihy Y, et al. Perinipple round-block technique for correction of tuberous/tubular breast deformity. Aesthetic Plast Surg. 1998;22:284-288.
2. Spear SL, Kassan M, Little JW. Guidelines in concentric mastopexy. Plast Reconstr Surg. 1990;85:961-966.

A 21-year-old woman desires surgical correction because her left breast has an abnormal appearance. On examination, the diameter of the left breast is more narrow at the base than at the midportion, and there is superior displacement of the inframammary fold. The areola is disproportionally enlarged, and the breast tissue appears to be herniating into the areola. The left cup size of her bra is 32B, and the right cup size is 32C. The right breast is normal.

Which of the following is the most appropriate management?

(A) Right-sided vertical breast reduction
(B) Pedicled TRAM flap reconstruction of the left breast
(C) Wise-pattern breast reduction on the right with lowering of the inframammary fold
(D) Augmentation mammaplasty on the left using a saline-filled implant
(E) Augmentation mammaplasty on the left with radial scoring and areolar reduction

The correct response is Option E.

This patient has a tuberous, or constricted, breast deformity. Affected patients have unilateral narrowing of the breast; the breast tissue appears to be herniating into the areola. In order to adequately correct this deformity, implant augmentation mammaplasty should be combined with repositioning of the inframammary fold, radial scoring of the breast parenchyma, and reduction of the herniated tissue and areola. This will correct the size and shape discrepancies, resulting in a left breast that appears similar to the unaffected right breast.

The right breast should not be reduced by any method to match the size and shape of the abnormal left breast. TRAM flap reconstruction is associated with significantly higher morbidity and should not be performed as initial management. Implantation alone will enlarge the left breast but will not correct the abnormal shape of the breast.

References
1. Grolleau JL, Lanfrey E, Lavigne B, et al. Breast base anomalies: treatment strategy for tuberous breasts, minor deformities, and asymmetry. Plast Reconstr Surg. 1999;104:2040-2048.
2. Meara JG, Kolker A, Bartlett G, et al. Tuberous breast deformity: principles and practice. Ann Plast Surg. 2000;45:607-611.

In a 21-year-old woman considering augmentation mammaplasty with saline-filled implants, which of the following is appropriate advice concerning potential complications of the procedure?

(A) Breast implants do not affect mammographic visualization of all breast tissue
(B) Capsular contracture requiring revision occurs in 2% of patients
(C) Infection is more common than hematoma
(D) Revision procedures are performed in 25% of patients within the first 10 years
(E) The risk for deflation is approximately 10% annually

The correct response is Option D.

Potential complications of augmentation mammaplasty include the development of infection, deflation of the implant, capsular contracture, breast asymmetry, and visible rippling in patients who have saline implants. One study of 884 women who underwent augmentation mammaplasty reported that 31% developed implant changes, leakage, or capsulotomy; another study of 450 mammaplasty patients showed that approximately 25% underwent at least one additional procedure during the 13-year follow-up period. Because parturition, aging, and weight gain or loss typically result in changes in the breast parenchyma, it is likely that the appearance of the implants will also change over time and that further surgery will be required.

Even though specialized views are required for mammography screening in patients with breast implants, it is estimated that approximately 5% of the breast parenchyma is not fully visible on a mammogram. The two studies described above reported rates of significant capsular contracture ranging from 20% to 25%. Hematoma occurred in 3% of implant patients, but only 1% of patients developed infection. Deflation occurred in 1% of patients annually.
References
1. Cunningham BL, Lokeh A, Gutowski KA. Saline-filled breast implant safety and efficacy: a multicenter retrospective review. Plast Reconstr Surg. 2000;105:2143-2149.
2. Fryzek JP, Signorello LB, Hakelius L, et al. Local complications and subsequent symptom reporting among women with cosmetic breast implants. Plast Reconstr Surg. 2001;107:214-221.

Which of the following is the most common cutaneous branching pattern of the fourth intercostal nerve as it supplies innervation to the nipple-areola complex?

(A) Anterior
(B) Central
(C) Inferior
(D) Lateral
(E) Superior

The correct response is Option D.

The anterior and lateral cutaneous branches of the third, fourth, and fifth intercostal nerves supply the primary innervation to the nipple-areola complex; the fourth lateral cutaneous branch and third and fourth anterior cutaneous branches provide innervation most consistently. The anterior cutaneous branches course superficially within the subcutaneous tissue and terminate at the medial areolar border. In 93% of patients undergoing breast surgery, the lateral cutaneous branches coursed deeply within the pectoral fascia and reached the nipple from its posterior surface. In contrast, 7% of patients undergoing breast dissection had lateral cutaneous branches coursing superficially within the subcutaneous fat, reaching the nipple from its lateral side.

Anatomic studies of the intercostal nerves have failed to identify any central, inferior, or superior cutaneous branches to the nipple-areola complex.

References
1. Greuse M, Hamdi M, DeMey A. Breast sensitivity after vertical mammaplasty. Plast Reconstr Surg. 2001;107:970-976.
2. Hamdi M, Greuse M, Nemec E, et al. Breast sensation after superior pedicle versus inferior pedicle mammaplasty: anatomical and histological evaluation. Br J Plast Surg. 2001;54:43-46.
3. Schlenz I, Kuzbari R, Gruber H, et al. The sensitivity of the nipple-areola complex: an anatomic study. Plast Reconstr Surg. 2000;105:905-909.

Which of the following proteins has been implicated in the pathogenesis of breast implant capsule formation?

(A) Albumin
(B) Fibrinogen
(C) Complement
(D) IgG
The correct response is Option B.

The surface-bound protein fibrinogen has been implicated in the generation of inflammatory responses to biomaterials (ie, implants); early protein absorption of these biomaterials mediates the foreign body response. Understanding the intricate pathways that result in fibrinogen absorption and its subsequent inflammatory response, leading to capsule formation, may aid in the prevention and management of breast implant capsular contracture.

Other dominant proteins in the body, such as albumin, complement, and immunoglobulin G (IgG), have not been shown to play a critical role in capsule formation resulting from foreign body reaction.

References
1. Kottke-Marchant K, Anderson JM, Umemura Y, et al. Effect of albumin coating on the in vitro blood compatibility of Dacron arterial prostheses. Biomaterials. 1989;10:147-155.
2. Tang L, Eaton JW. Fibrin(ogen) mediates acute inflammatory responses to biomaterials. J Exp Med. 1993;178:2147-2156.
3. Tang L, Eaton JW. Natural responses to unnatural materials: a molecular mechanism for foreign body reactions. Molec Med. 1999;5:351-358.

Silicone polymers are important biomaterials because they have which of the following characteristics?

(A) Biological inertness
(B) Hydrophilic nature
(C) Impermeability
(D) Resistance to contamination in the manufacturing process
The correct response is Option A.

Silicones such as polydimethylsiloxane are widely used materials for implantation because of their biocompatibility or biological inertness. These polymers are based on the element silicon and are often used as oils, elastomers, and gels. Because silicones are hydrophobic, not hydrophilic, water is repelled and the implanted materials will therefore not interact with enzymes or chemicals within the body. Silicone polymers are semipermeable materials often used in drug delivery systems. Because these materials have relatively poor tensile strength, strict standards are imposed during the production of medical-grade silicone because of the propensity for contamination.

References
1. Brody GS. Silicone technology for the plastic surgeon. Clin Plast Surg. 1988;15:517-520.
2. Holmes RE. Alloplastic materials. In: McCarthy JG, ed. Plastic Surgery. Philadelphia, Pa: WB Saunders Co; 1990;1:698.

A 36-year-old woman is being evaluated 17 years after undergoing augmentation mammaplasty with silicone gel implants. On examination, the implants are soft and minimally palpable; she reports no complications. This patient is at risk for which of the following?

(A) Implant rupture
(B) Increased silicon levels in breast milk
(C) Rheumatoid arthritis
(D) Scleroderma
(E) Silicone synovitis

The correct response is Option A.

This 36-year-old woman is at risk for implant rupture, which has been shown in recent studies to increase proportionately with the age of the implant. One retrospective study determined the mean age of implant rupture to be 13.4 years. MRI is most effective for assessing potential implant rupture, which in one study was reported in as many as 71% of implant patients. Another study showed that 50% of patients who had had implants for seven to 10 years showed evidence of rupture or hemorrhage on MRI.

Although attempts have been made to associate silicone gel implants to the onset of rheumatoid symptoms in children who were breast-fed, one study showed no difference in silicone levels measured in breast milk in women with implants versus controls. In addition, several large epidemiologic studies have shown no link between silicone gel implants and the subsequent development of either rheumatologic (ie, rheumatoid arthritis) or connective tissue (ie, scleroderma) diseases. Silicone synovitis occurs in patients who have silicone joint prostheses, but not in patients with silicone gel breast implants.

References
1. Beekman WH, Feitz R, Hage JJ, et al. Life span of silicone gel-filled mammary prostheses. Plast Reconstr Surg. 1997;100:1723-1726.
2. Blackburn WD Jr, Grotting JC, Everson MP. Lack of evidence of systemic inflammatory rheumatic disorders in symptomatic women with breast implants. Plast Reconstr Surg. 1997;99:1054-1060.
3. Brody GS. On the safety of breast implants. Plast Reconstr Surg. 1997;100:1314-1321.
4. Lewin SL, Miller TA. A review of epidemiologic studies analyzing the relationship between breast implants and connective tissue diseases. Plast Reconstr Surg. 1997;100:1309-1313.
5. Rohrich RJ, Adams WP Jr, Beran SJ, et al. An analysis of silicone gel-filled breast implants: diagnosis and failure rates. Plast Reconstr Surg. 1998;102:2304-2308.
6. Semple JL, Lugowski SJ, Baines CJ, et al. Breast milk contamination and silicone implants: preliminary results using silicon as a proxy measurement for silicone. Plast Reconstr Surg. 1998;102:528-533.