In-Service Exam
Breast Augmentation 2003





PHOTO

The patient shown in the photograph has which of the following types of ptosis?

(A) Pseudoptosis
(B) First-degree ptosis
(C) Second-degree ptosis
(D) Third-degree ptosis
The correct response is Option C.

The patient in the photograph has second-degree ptosis. In this condition, the nipple is located beneath the inframammary fold, but above the lowest level of the breast.

In patients with pseudoptosis, also known as glandular ptosis, the breast mass descends from behind the nipple-areola complex, but the nipple remains above the level of the inframammary fold. First-degree ptosis is characterized by descent of the nipple to the level of the inframammary fold. Positioning of the nipple at the lowest point on the breast is consistent with third-degree ptosis.

References
1. Bostwick J. Plastic and Reconstructive Breast Surgery. Saint Louis, Mo: Quality Medical Publishing; 1990;1:57-97.
2. Brink RR. Management of true ptosis of the breast. Plast Reconstr Surg. 1993;91:657-662.
3. Regnault P. Breast ptosis: definition and treatment. Clin Plast Surg. 1976;3:193-203.

In patients with polymastia, accessory mammary structures are most frequently found at which of the following sites?

(A) Neck
(B) Axilla
(C) Thigh
(D) Buttock
(E) Vulva

The correct response is Option B.

Accessory mammary structures are found along the embryonic milk line, which forms on the ventrolateral body wall from the axilla to the groin. These include most supernumerary breasts, which are most often found in the axilla, just above or below the normal breast, or in the groin. True accessory mammary structures occur less frequently in the inner surfaces of the upper arm and inner side of the thigh or the vulva.

Ectopic mammary structures are found outside of the embryonic milk line and represent either true ectopia or displacement of the milk line. Ectopic breast tissue has been reported in the midline and on the face, ear, neck, back, buttock, and outer thigh.

References
1. Bostwick J. Plastic and Reconstructive Breast Surgery. Saint Louis, Mo: Quality Medical Publishing; 1990;1:57-97.
2. Georgiade NG, Georgiade GS, Riefkohl R. Esthetic breast surgery. In: McCarthy JG, ed. Plastic Surgery. Philadelphia, Pa: WB Saunders Co; 1990;6:3839-3896.
3. Skandalakis JE, Gray SW, Ricketts R, et al. The anterior body wall. In: Skandalakis JE, ed. Embryology for Surgeons. Baltimore, Md: Williams & Wilkins; 1994:540-593.

Which of the following factors is most critical in determining the need for breast contouring following removal of breast implants?

(A) Age of the patient
(B) Amount of breast tissue overlying the implant
(C) Degree of preoperative ptosis
(D) Size of the areola
(E) Size and position of the implant

The correct response is Option C.

The degree of ptosis seen preoperatively is most important in determining the need for breast contouring following explantation. Because ptosis remains relatively unchanged following implant removal, contouring should be considered in women who have ptosis that is classified preoperatively as grade II or III.

The thickness of residual breast parenchyma best determines the viability of performing breast contouring concomitantly with explantation. The breast tissue should have a minimum thickness of 4 cm to allow for vascularity of the overlying skin and of the separated glandular-nipple flap. This is best assessed by performing a breast pinch test superiorly and inferiorly.

In determining the type of mastopexy that is most appropriate for each patient undergoing explantation, the elasticity of the skin, size and positioning of the implant, and size of the areola should be assessed. Circumareolar mastopexy is an option in women with areolae that are larger than 50 mm.

References
1. Rohrich RJ, Beran SJ, Restifo RJ. Aesthetic management of the breast following explantation: evaluation and mastopexy options. Plast Reconstr Surg. 1998;101:827.
2. Spear SL, Giese SY, Ducic I. Concentric mastopexy revisited. Plast Reconstr Surg. 2001;107:1294.

Which of the following findings is most likely in a patient with Poland syndrome?

(A) Anomalies of the feet
(B) Bilateral abnormalities of the ribs
(C) Breast hypertrophy
(D) Hypoplasia of the pectoralis major muscle
(E) Polythelia

The correct response is Option D.

Poland syndrome is a congenital anomaly that is characterized by unilateral aplasia or hypoplasia of the pectoralis major muscle and adjacent musculoskeletal components. Chest wall anomalies can also be unilateral and include aplasia or hypoplasia of the breast or nipple, partial agenesis of the ribs and sternum, and anomalies of the shoulder girdle. Ipsilateral hand anomalies are common. In severe forms of the disease, the pectoralis, latissimus, and serratus muscles are completely absent.

Poland syndrome typically occurs sporadically and its etiology is not fully understood. Men and women are affected equally. Despite the absence of structures of the chest wall, patients have minimal physical disability. Appropriate reconstructive options include transfer of the latissimus in men and women, with the addition of submuscular augmentation mammaplasty in women.

References
1. Argenta LC, Vanderkolk C, Friedman RJ, et al. Refinements in reconstruction of congenital breast deformities. Plast Reconstr Surg. 1985;76:73-82.
2. Seyfer AE, Icochea R, Graeber GM. Poland's anomaly: natural history and long-term results of chest wall reconstruction in 33 patients. Ann Surg. 1988;208:776-782.

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.