(A) Capsular contracture
(B) Deflation
(C) Hypertrophic scarring
(D) Infection
(E) Malpositioning of the implant

The correct response is Option E.

Transaxillary breast augmentation is an established technique that allows the surgeon to make the incision in an aesthetically acceptable area, where it can be hidden. However, one disadvantage of traditional transaxillary augmentation is a lack of visualization of the implant pocket, necessitating blind, blunt dissection at the origin of the pectoral muscle. This limitation may result in improper implant placement, leading to malpositioning of the implant and poor aesthetic results in some patients. In contrast, endoscopic transaxillary augmentation allows the surgeon to divide the origin of the pectoral muscle under direct visualization, thereby effectively lowering the inframammary crease.
Endoscopic techniques have not been shown to significantly decrease the incidence of capsular contracture, hypertrophic scarring, or infection. The method of pocket dissection has no effect on the rate of deflation.

References
1. Howard PS, Oslin BD, Moore JR. Endoscopic transaxillary submuscular augmentation mammaplasty with textured saline breast implants. Ann Plast Surg. 1996;37:12-17.
2. Howard PS. The role of endoscopy and implant texture in transaxillary submuscular breast augmentation. Ann Plast Surg. 1999;42:245-248.
3. Price CI, Eaves FF III, Nahai F, et al. Endoscopic transaxillary subpectoral breast augmentation. Plast Reconstr Surg. 1994;94:612-619.
4. Villafane O, Garcia-Tutor E, Taggart I. Endoscopic transaxillary subglandular breast augmentation using silicone gel textured implants. Aesthetic Plast Surg. 2000;24:212-215.

Elongation and laxity of which of the following structures are most likely to result in breast ptosis?

(A) Clavipectoral fascia
(B) Cooper’s ligaments
(C) Costoclavicular ligaments
(D) Superficial fascia of the breast
(E) Superficial fascia of the pectoralis muscle

The correct response is Option B.

Patients with breast ptosis have drooping of the breast parenchyma, skin, and/or nipple-areola complex occurring as a result of aging, pregnancy, lactation, or weight loss. Anatomically, ptosis is caused by disruption or elongation of Cooper’s ligaments, which are fibrous projections that arise from the breast tissue and fuse with the superficial fascia and dermis of the breast. These ligaments attach the breast parenchyma to the overlying skin. Tumors can stretch these ligaments and cause dimpling and retraction of the skin.

Several mastopexy techniques have used absorbable meshes, deep anchoring sutures, or crossing parenchymal slings in an attempt to recreate the tight Cooper’s ligaments and thus correct the ptosis. However, scarring and recurrence of ptosis are frequent complications.

The clavipectoral fascia covers the axilla and pectoralis minor muscle; this layer is encountered during axillary dissection. The costoclavicular ligaments anchor the clavicle to the chest beneath the medial superior pole of the breast, but do not enter the breast parenchyma.

The superficial fascia of the breast is a filmy, white layer of connective tissue located 2 to 15 mm deep to the skin. The deep layer of the superficial fascia envelopes the breast posteriorly. A loose areolar plane is present between the superficial fascia of the breast and the deep fascia of the pectoralis muscle, and facilitates removal of the breast from the pectoralis muscle during mastectomy.

The superficial fascia of the pectoralis muscle covers the muscle but does not extend into the breast.

References
1. Bostwick J III, ed. Plastic and Reconstructive Breast Surgery. Saint Louis, Mo: Quality Medical Publishing; 1990.
2. Lockwood T. Reduction with superficial fascial skin suspension. Plast Reconstr Surg. 1999; 103:1411-1419.
3. Wuring E. Refinement of central pedicle reconstruction by application of the ligamentous suspension. Plast Reconstr Surg. 1999;103:1400-1409.

In women undergoing augmentation mammaplasty with saline-filled implants, which of the following techniques is most likely to decrease the longevity of the implant and lead to early rupture?

(A) Underfilling of the implants below the manufacturer’s recommended minimum
(B) Filling of the implants to the manufacturer’s recommended minimum
(C) Filling of the implants to the volume between the manufacturer’s recommended minimum and maximum (D) Filling of the implants to the manufacturer’s recommended maximum
(E) Overfilling of the implants above the manufacturer’s recommended maximum

The correct response is Option A.

Adequate fill volume is recommended to increase the longevity of a breast implant. This decreases both fold-flaw failure and the potential for premature failure resulting from filling the implant at or below the manufacturer’s minimum volume. Implants are softer and more sloping at lower levels of fill volume, but these “underfilled” implants have also been shown to wrinkle more, leading to a shorter lifespan because of stresses induced by wrinkling. As the volume of the implant increases, palpable and visible wrinkling decreases, resulting in increased longevity.

Some studies have also shown that implant longevity can be maximized by filling the implants to the volume at which they exhibit the least wrinkles, even if it exceeds the manufacturer’s maximum recommended volume. However, this technique, known as “overfill,” is not recommended.

References
1. Dowden RV, Reisman NR. Breast implant overfill, optimal fill, and the standard of care. Plast Reconstr Surg. 1999;104:1185.
2. Dowden RV. Saline breast implant fill issues. Clin Plast Surg. 2002;28:445-450.

Which of the following techniques is indicated to preserve sensation to the nipple-areola complex in a patient undergoing augmentation mammaplasty?

(A) Avoiding periareolar incisions
(B) Avoiding sharp dissection near the clavicle
(C) Identifying and tagging of the sensory nerves as they exit the fascia
(D) Performing blunt dissection lateral to the lateral edge of the pectoralis muscle
(E) Positioning the implant subpectorally

The correct response is Option D.

Performing blunt dissection lateral to the lateral edge of the pectoralis muscle only is indicated to preserve sensation to the nipple-areola complex. The fourth and fifth anterolateral intercostal nerves primarily supply sensation to the nipple-areola complex; these nerves perforate the fascia just lateral to the pectoralis muscle through the interdigitation of the serratus anterior muscle. By performing blunt dissection only lateral to the pectoralis muscle, these nerves are stretched but not cut. Although the stretching of sensory nerves may still result in loss of sensation, it is more likely to be temporary than if the nerves are cut sharply.

Periareolar incisions do not disrupt the sensory innervation to the nipple-areola complex. It is not necessary to identify and tag the sensory nerves as they exit the fascia. The positioning of the implant (whether subpectoral or subglandular) and the type of dissection performed in the superior aspect of the pocket also will not affect sensation.

References
1. Bostwick J III, ed. Plastic and Reconstructive Breast Surgery. Saint Louis, Mo: Quality Medical Publishing; 1990:64-65.
2. Georgiade S. Hypermastia and ptosis. In: Georgiade GS, Riefkohl R, Levin LS, eds. Plastic, Maxillofacial and Reconstructive Surgery. Baltimore, Md: Williams & Wilkins; 1997:752.

In a 50-year-old woman who underwent augmentation mammaplasty with silicone implants 12 years ago, a silicone granuloma is noted in the axillary region on clinical examination. Which of the following statements best characterizes this finding?

(A) Silicone granulomas are a frequent complication following augmentation mammaplasty or reconstruction with silicone implants
(B) Silicone granulomas indicate a link to the existence of implant-related systemic disease
(C) Silicone granulomas represent a common tissue response to foreign materials
(D) Surgical resection is rarely indicated

The correct response is Option C.

Although silicone granulomas are a well-recognized tissue response to the presence of foreign material, such as silicone, these granulomas are found only rarely in patients who have undergone augmentation mammaplasty or reconstruction with silicone gel breast implants. Any granulomas that are detected should be resected if they are symptomatic or of diagnostic concern. No evidence has been presented in peer-reviewed scientific literature to support the theory that silicone granulomas help to cause implant-related systemic disease, and in fact the existence of implant-related systemic disease is controversial in itself.

References
1. Austad ED. Breast implant-related silicone granulomas: the literature and litigation. Plast Reconstr Surg. 2002;109:1724.
2. Williams CW. Silicone gel granuloma following compressive mammography. Aesthet Plast Surg. 1991;15:49.