The most likely cause is denervation of which of the following nerves during mastectomy?

(A) Fourth intercostal
(B) Lateral pectoral
(C) Long thoracic
(D) Medial pectoral
(E) Thoracodorsal

The correct response is Option D.

The minimal bulk in the inferior and lateral portions of the right pectoralis major muscle in this patient most likely results from denervation of the medial pectoral nerve, which is injured often during mastectomy. The pectoralis major is innervated by the medial and lateral pectoral nerves, named for their respective cords of origin from the brachial plexus. The lateral nerve, which arises from C5-6, actually supplies the medial portion of the pectoralis major muscle, and the medial nerve, derived from C8-T1, supplies the lower and lateral sternal portion of the pectoralis major muscle and the pectoralis minor muscle.

Because injury to the medial pectoral nerve results in severe atrophy of the lower half of the muscle, implant coverage will be sparse in this region. It is important for the plastic surgeon to assess the status of the pectoralis muscle before attempting implant augmentation; this can be accomplished by having the patient place her hands on her hips and contract her chest muscles.

The fourth intercostal nerve supplies sensation to the nipple-areola complex. The long thoracic nerve, commonly referred to as the long thoracic nerve of Bell, supplies motor innervation to the serratus muscle, and injury may result in winging of the scapula. The thoracodorsal nerve provides innervation to the latissimus dorsi muscle.

References
1. Bostwick J III, ed. Plastic and Reconstructive Breast Surgery. Saint Louis, Mo: Quality Medical Publishing; 1990.
2. Haagensen CD. Disease of the Breast. Philadelphia, Pa: WB Saunders Co; 1971:1-28.

Which of the following is the primary advantage of performing breast reconstruction with an extended latissimus dorsi myocutaneous flap instead of the standard latissimus dorsi myocutaneous flap?

(A) Decreased donor site scarring
(B) Decreased incidence of seroma at the donor site
(C) Decreased need for adjuvant breast implantation
(D) Decreased need for division of the humeral tendon attachment
(E) Decreased risk for flap loss

The correct response is Option C.

The primary advantage of the extended latissimus dorsi flap is the autogenous tissue it provides, which can be used to enhance breast volume without the need for an implant. The standard latissimus dorsi myocutaneous flap was one of the first created for breast reconstruction. However, with the emergence of the TRAM flap, the latissimus dorsi flap has become a secondary choice for autologous reconstruction for many surgeons because it often does not provide sufficient volume and is, instead, often used in combination with an implant.

Variations of the latissimus dorsi flap have been created to increase volume and obviate the need for an implant. The first extended latissimus dorsi flap, described in 1983, was designed to include fat and fascia from the parascapular and scapular regions and fat from the lumbar spine. This transfer of additional tissue from the back eliminates the need for an implant; therefore, potential complications associated with implants, such as the development of capsular contracture and deformation of the reconstructed breast, are avoided. The technique was later modified by creating a fleur-de-lis skin paddle, which carries additional fat on the surface of the latissimus dorsi muscle and is thus a totally autogenous latissimus dorsi flap.

The contour and scarring of the donor site following flap transfer are acceptable. However, other complications, such as seroma formation and wound necrosis, can be a significant concern. Division of the humeral tendon allows for
increased mobility of the flap. Partial flap and/or fat necrosis are more commonly associated with the extended flap than the standard flap.

References
1. Chang D, Youssef A, Cha S, et al. Autologous breast reconstruction with the extended latissimus dorsi flap. Plast Reconstr Surg. 2002;110:751-761.
2. Delay E, Gounot N, Bouillot A. Autologous latissimus breast reconstruction: a 3-year clinical experience with 100 patients. Plast Reconstr Surg. 1998;102:1461.
3. Horn MA, Cimino V, Angelats J. Modified autogenous latissimus breast reconstruction and the box top nipple. Plast Reconstr Surg. 2000;106:763.

A 36-year-old woman with carcinoma of the breast is scheduled to undergo modified radical mastectomy followed by postoperative radiation therapy. Which of the following operative techniques is most likely to provide the best aesthetic reconstruction?

(A) Immediate reconstruction with autologous tissue
(B) Immediate reconstruction with autologous tissue and an implant
(C) Immediate reconstruction with an expander and a saline-filled implant
(D) Delayed reconstruction with autologous tissue
(E) Delayed reconstruction with an expander and a silicone gel-filled implant

The correct response is Option D.

Delayed reconstruction with autologous tissue will provide the best aesthetic reconstruction in this patient. Transfer of autologous tissue alone is the best method in any patient who has previously undergone radiation therapy. In the absence of autologous reconstruction, a latissimus dorsi flap can be used, especially in patients who are not good candidates for TRAM flap reconstruction or as a salvage technique following periprosthetic contracture in patients who underwent implant reconstruction following radiation therapy.

One recent study evaluated patients who underwent immediate TRAM flap reconstruction followed by radiation therapy and compared them with patients who had radiation therapy first followed by TRAM flap reconstruction. Although the incidence of early complications did not differ significantly between the two groups, late complications were much more common in the immediate reconstruction group than in the delayed reconstruction group. In addition, 28% of those patients undergoing immediate reconstruction experienced severe shrinkage and contraction of the flap and subsequently required an additional procedure for correction. Therefore, in patients who require radiation therapy following mastectomy, it is recommended that reconstruction is delayed until radiation therapy has been completed.

Use of an implant, whether saline- or silicone gel-filled, is associated with a significant increase in capsular contracture and other complications in patients who have previously undergone radiation therapy.

References
1. Spear SL, Onyewu C. Staged breast reconstruction with saline-filled implants in the irradiated breast: recent trends and therapeutic implications. Plast Reconstr Surg. 2000;105:930.
2. Tran N, Chang D, Gupta A, et al. Comparison of immediate and delayed free TRAM flap breast reconstruction in patients receiving postmastectomy radiation therapy. Plast Reconstr Surg. 2001;108:78-82.

In a 30-year-old woman who carries the BRCA-2 genetic mutation, the lifetime risk of development of breast carcinoma is closest to what percentage?

(A) 10%
(B) 20%
(C) 40%
(D) 60%
(E) 100%

The correct response is Option D.

In persons who carry the BRCA-1 or BRCA-2 genetic mutation, the lifetime risk for development of breast carcinoma varies from 50% to 85%. Although initial studies showed a lifetime risk of 85%, more recent studies have reported that the risk is actually closer to 56%. Genetic testing for BRCA mutations is now available, and patients who carry a mutation may wish to undergo bilateral mastectomy and reconstruction.

The BRCA genes are autosomal dominant genes whose loci code for proteins; these proteins facilitate DNA repair and thus suppress tumor growth. Although only 5% to 10% of all cancerous tumors have been shown to result from the BRCA genes, a mutation of either gene results in a marked increase in the incidence of carcinoma.

BRCA-1, whose locus lies on chromosome 17, has also been linked to carcinoma of the ovaries, prostate, and colon. More than 100 different mutations of this gene have been reported. The BRCA-2 locus is located on chromosome 13. This mutation is associated with an increased risk for carcinoma of the breast, but not with ovarian carcinoma. According to the results of recent studies, administration of tamoxifen appears to decrease the risk for breast carcinoma in patients with the BRCA-2 mutation.

References
1. Honig SF. Incidence, trends, and the epidemiology of breast cancer. In: Spear SL, ed. Surgery of the Breast: Principles and Art. Philadelphia, Pa: Lippincott-Raven; 1998:3-21.
2. Struewing JP, Hartge P, Wacholder S, et al. The risk of cancer associated with specific mutations of BRCA1 and BRCA2 among Ashkenazi Jews. N Engl J Med. 1997;336:1401-1408.

Six hours after undergoing breast reconstruction with a free TRAM flap, a 35-year-old woman has swelling of the reconstructed area and bluish discoloration of the skin. A photograph is shown above. Capillary refill time is increased. Findings on Doppler ultrasonography of the flap are within normal limits.

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

(A) Fluid resuscitation
(B) Anticoagulant therapy
(C) Release of sutures and observation
(D) Operative exploration

The correct response is Option D.
This 35-year-old woman who underwent breast reconstruction now exhibits signs of venous outflow obstruction, including increased capillary refill time, dark or bluish discoloration of the skin, and swelling of the affected area. In addition, complete venous obstruction does not always manifest as abnormal findings on Doppler ultrasonography, and the Doppler signal may indeed fall within normal limits in many affected patients. Therefore, in the presence of these clinical signs, the only appropriate option is to perform repeat operative exploration.

Fluid resuscitation and anticoagulant therapy are not appropriate treatment of venous obstruction in patients who have undergone free tissue transfer. In the same way, release of the sutures will not resolve the obstruction.

References
1. Conrad MH, Adams WP Jr. Pharmacologic optimization of microsurgery in the new millennium. Plast Reconstr Surg. 2001;108:2088.
2. Shenaq SM, Sharma SK. Principles of microvascular surgery. In: Aston SJ, Beasley RW, Thorne CH, eds. Grabb & Smith’s Plastic Surgery. 5th ed. Philadelphia, Pa: Lippincott-Raven; 1997:73.