Which of the following is the most appropriate management?

(A) Hormone therapy
(B) Enucleation
(C) Subcutaneous mastectomy
(D) Simple mastectomy
(E) Reduction mammaplasty

The correct response is Option B.

This 16-year-old girl has fibroadenoma, which is the most common neoplasm of the breast in adolescents. Giant fibroadenomas are typically solitary, firm, nontender, benign lesions that develop at or soon after the onset of puberty. They are larger than 5 cm in diameter and double in size within a short time. Rapid enlargement of one breast is characteristic. Prominent veins are noted over the arc of the tumor; some patients develop skin ulcerations because of the pressure caused by the fibroadenoma. Enucleation is curative, and the risk for local recurrence is minimal.
Hormone therapy would only stimulate growth of the glands within the breast.

Mastectomy is excessive and unnecessary in patients with giant fibroadenoma.

Reduction mammaplasty is indicated for management of juvenile breast hypertrophy, which is characterized by diffuse enlargement of the breast without a palpable mass or nodes.

References
1. McGrath MH. Benign tumors of the teenage breast. Plast Reconstr Surg. 2000;105:218.
2. Souba WW. Evaluation and treatment of benign breast disorders. In: Bland KI, Copeland EM, eds. The Breast: Comprehensive Management of Benign and Malignant Diseases. Philadelphia, Pa: WB Saunders Co; 1991:715.

Sensation to the nipple-areola complex is provided primarily by which of the following nerves?

(A) Anterior cutaneous nerve from T3
(B) Anterior cutaneous nerve from T4
(C) Lateral cutaneous nerve from T4
(D) Medial cutaneous nerve from T5
(E) Posterior cutaneous nerve from T5

The correct response is Option C.

Sensation to the nipple-areola complex is primarily provided by the lateral cutaneous nerve from T4. The innervation of the skin of the breast is segmental and is derived from the dermatomes associated with breast development. Knowledge of this innervation is crucial before performing breast surgery.

The upper breast receives its sensation from the supraclavicular nerves that originate from the third and fourth branches of the cervical plexus. The medial and inferior aspects of the breast are innervated by small medial branches of the anterior cutaneous nerves. The lateral cutaneous branches course subcutaneously to provide sensation to the midclavicular region and contribute to the innervation of the areola.

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.

A 40-year-old woman has cyanosis of the right nipple one hour after undergoing bilateral breast reduction with removal of 1500 g of tissue on each side. Which of the following is the most appropriate management?

(A) Observation
(B) Application of leeches
(C) Hyperbaric oxygen therapy
(D) Release of the sutures
(E) Conversion of the nipple-areola complex to a split-thickness skin graft

The correct response is Option D.

The findings seen in this patient are consistent with necrosis of the nipple-areola complex. This condition can be caused by direct devascularization of the breast mound, torsion, or direct pressure on the nipple and areola. Appropriate management includes immediate decompression with release of the sutures and operative exploration. Excision of the nipple-areola complex with subsequent defatting and conversion to a full-thickness skin graft is indicated for those patients who have ischemia of the breast mound identified on operative exploration.

Free nipple grafting may be considered to decrease the risk for necrosis of the nipple-areola complex in women undergoing breast reduction with an estimated volume of resection of more than 1500 g on each side, a nipple transposition length of 25 cm or greater, or associated risk factors such as smoking or diabetes mellitus.

Although leeches can be used to relieve venous insufficiency, this process would need to be undertaken over several days to be effective. Hyperbaric oxygen therapy increases the oxygen content of the tissue but is also a lengthy process.

References
1. Hidalgo DA, Elliot LF, Palumbo S, et al. Current trends in breast reduction. Plast Reconstr Surg. 1999;104:806.
2. Spear SL, Burkes JB, Forman D. Experience with reduction mammaplasty following breast conservation surgery and radiation therapy. Plast Reconstr Surg. 1998;102:1913.

Gynecomastia is an adverse effect of administration of each of the following agents EXCEPT

(A) cimetidine (Tagamet)
(B) digitalis (Digoxin)
(C) minocycline (Minocin)
(D) spironolactone (Aldactone)
(E) zolpidem (Ambien)

The correct response is Option E.

Many agents have been linked to gynecomastia, such as amphetamines, cimetidine, digitalis, haloperidol, isoniazid, methyldopa, opiates, progestins, spironolactone, and tricyclic antidepressants. Associated conditions include obesity, liver disease, kidney failure, adrenal tumors, hyperthyroidism, and hypothyroidism. Gynecomastia can also be caused by increased estrogen levels (men with testicular tumors or who use androgen-based agents) or decreased estrogen levels (men with Klinefelter syndrome or who undergo orchiectomy).

Zolpidem has not been shown to be a cause of gynecomastia.

References
1. Bostwick J. Plastic and Reconstructive Breast Surgery. Saint Louis, Mo: Quality Medical Publishing; 1990;1:465-516.
2. Sifton DW, ed. Physicians' Desk Reference. Montvale, NJ: Medical Economics Co; 2002:2823-2825.
3. Tuerk M. Medications that cause gynecomastia. Plast Reconstr Surg. 1993;92:1411.