(A) Age of the patient
(B) Initial tumor margins
(C) Location of the tumor
(D) Total volume of tissue resected
(E) Tumor size

The correct response is Option B.
In this patient who has invasive ductal carcinoma, the initial tumor margins will determine the most appropriate next step in management. If the tumor was not completely excised during the original reduction mammaplasty procedure, completion mastectomy is recommended. Because of the potential for shifting of the tissues following reduction, possible tumor seeding, and residual lymphatic spread, this procedure is advocated for nearly all patients who did not undergo complete tumor excision at the time of breast reduction. Even if the tumor is excised completely with adequate margins, the axillary region should be evaluated because chemotherapy and radiation therapy may still be required.

Occult breast carcinoma has been identified in as many as 2% of women undergoing reduction mammaplasty. In addition, occult carcinoma was found in 4.6% of women who underwent a "balancing reduction" following mastectomy. There is some discrepancy in the incidence of occult carcinoma related to the inclusion or exclusion of in situ lesions. Women who have occult malignancies identified during breast reduction are more likely to be younger and to have lobular tumors without palpable lymph nodes.

The age of the patient, total volume of tissue resected, location of the tumor, and tumor size have not been shown to influence treatment options independent of the surgical margins obtained at the time of reduction mammaplasty.

References
1. Brown MH, Weinberg M, Chong N, et al. A cohort study of breast cancer risk in breast reduction patients. Plast Reconstr Surg. 1999;103:1674.
2. Jansen DA, Murphy M, Kind G, et al. Breast cancer in reduction mammoplasty: case reports and a survey of plastic surgeons. Plast Reconstr Surg. 1998;101:361-364.
3. Tang CL, Brown MH, Levine R, et al. Breast cancer found at the time of breast reduction. Plast Reconstr Surg. 1999;103:1682-1686.
4. Tang CL, Brown MH, Levine R, et al. A follow-up study of 105 women with breast cancer following reduction mammaplasty. Plast Reconstr Surg. 1999;103:1687-1690.

A 45-year-old woman is scheduled to undergo mastectomy of the right breast followed by reconstruction using a free TRAM flap. She has a 15 pack/year history of cigarette smoking. This patient is at increased risk for development of each of the following postoperative complications EXCEPT

(A) abdominal flap necrosis
(B) fat necrosis
(C) hernia
(D) mastectomy skin flap necrosis

The correct response is Option B.

The free TRAM flap is frequently advocated for breast reconstruction in high-risk patients, including those who smoke, because of its enhanced blood supply; however, patients who smoke are still at increased risk for development of complications. One large retrospective study showed that patients who smoked were at greater risk for developing hernia and necrosis of the mastectomy skin flap and abdominal flap when compared with nonsmokers undergoing breast reconstruction with the free TRAM flap. Because patients who had a 10 pack/year or greater history of smoking were at greatest risk for perioperative complications, it has been suggested that reconstruction should be delayed until the patient has stopped smoking for at least four weeks. Studies have shown no significant increase in the rate of fat necrosis, flap loss, or vessel thrombosis in patients who smoked when compared with nonsmokers.

References
1. Chang DW, Reece GP, Wang B, et al. Effect of smoking on complications in patients undergoing free TRAM flap breast reconstruction. Plast Reconstr Surg. 2000;105:274.
2. Chang LD, Bunke G, Slezak S. Cigarette smoking, plastic surgery, and microsurgery. J Reconstr Microsurg. 1996;12:467.
3. Reus WF, Robison MC, Zachary L. Acute effects of tobacco smoking on blood flow and cutaneous micro circulation. Br J Plast Surg. 1994;37:213.
4. Van Adrichem LN, Hoegen R, Hovious SE, et al. The effect of cigarette smoking on the survival of free vascularized and pedicled epigastric flaps in the rat. Plast Reconstr Surg. 1996;97:86.