(A) Calcifications
(B) Fat necrosis
(C) Oil cysts
(D) Periareolar fibrosis
(E) Skin thickening

The correct response is Option A.

Mammography is recommended in women older than age 35 years for detection of carcinoma. One recent study, involving women who underwent bilateral reduction mammaplasty using an inferior pedicle technique, examined findings on radiographs of the breasts six to 18 months after surgery. According to the results of this study, the most common findings were parenchymal redistribution (90.2%) and elevation of the nipple (84.9%) caused by a downward shifting of the breast tissue. Calcifications occurred in 25.6% of patients, retroareolar fibrotic banding from the
transposed flap in 20.3% of patients, and oil cysts resulting from localized fat necrosis in 19.4% of patients. Thickening of the skin and areola caused by scar tissue were less common findings. Because such studies have delineated the “routine” mammography findings in patients who have undergone reduction mammaplasty, lesions can be diagnosed more easily and unnecessary biopsy procedures can be avoided.

References
1. Danikas D, Theodorou SJ, Kokkalis G, et al. Mammographic findings following reduction mammoplasty. Aesthetic Plast Surg. 2001;25:283-285.
2. Keleher AJ, Langstein HN, Ames FC, et al. Breast cancer in reduction mammaplasty specimens: case reports and guidelines. Breast J. 2003;9:120-125.

A 13-year-old boy with gynecomastia desires corrective surgery. An initial preoperative evaluation of this patient should include examination of which of the following?

(A) Eyes
(B) Thyroid gland
(C) Pectoralis muscle
(D) Abdomen
(E) Genitalia

The correct response is Option E.

The genitalia should be examined in this 13-year-old boy with gynecomastia. Although most adolescent boys with breast development do not exhibit other signs of feminization caused by hormonal excess or other genetic problems, examination of the genitalia could reveal an underlying cause of the gynecomastia. Testicular tumors are typically palpable on physical examination, and some adolescent boys will have nonpalpable and/or undescended testes. In patients with these findings, genetic and/or endocrine evaluation is required before any operative procedures are performed.

Visual fields may be altered in a patient who has a pituitary tumor, and patients with adrenal tumors may have palpable abdominal masses. Examination of these sites should be performed secondarily to examination of the genitalia.

Thyroid abnormalities are not associated with gynecomastia. The pectoralis muscle may be partially absent in patients with Poland syndrome but not in patients with gynecomastia.

References
1. Braunstein GD, Glassman HA. Gynecomastia. Curr Ther Endocrinol Metab. 1997;6:401-404.
2. Neuman JF. Evaluation and treatment of gynecomastia. Am Fam Physician. 1997;55:1835-1844, 1849-1850.

A 35-year-old woman is scheduled to undergo reduction mammaplasty with removal of approximately 700 g of tissue bilaterally using an inferior pedicle technique. During preoperative marking of the patient, which of the following points should be used as a landmark to best determine the new position of the nipple?

(A) 7 cm above the inframammary fold
(B) 21 cm below the sternal notch
(C) Inframammary fold
(D) Midhumerus
(E) Xiphoid

The correct response is Option C.

In patients undergoing reduction mammaplasty, the new nipple position should be determined when the patient is in an upright position, before the procedure is performed. During preoperative marking, the inframammary fold is used as a landmark to determine the most appropriate position of the nipple on the midbreast line. This is consistent regardless of the reduction technique performed.

The midhumerus, the xiphoid, and the measured distance below the sternal notch (19 to 23 cm) are helpful but less reliable landmarks. The measurement of 7 cm above the inframammary fold is essential during surgery, when the new nipple position is being marked during closure of the incisions, but is not a reliable preoperative measurement.

References
1. Bostwick J, ed. Aesthetic and Reconstructive Breast Surgery. Saint Louis, Mo: CV Mosby Co; 1983.
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.

The sensation to the nipple-areolar complex is derived from the

(A) anterior cutaneous branches of the sixth and seventh intercostal nerves
(B) anterolateral branches of the third through fifth intercostal nerves
(C) branches of the lateral pectoral nerve
(D) nerves of the cervical plexus
(E) nerves traveling with the internal mammary artery

The correct response is Option B.

The sensation to the nipple-areolar complex is derived primarily from the fourth intercostal nerve, with lesser contributions from the third and fifth intercostal nerves. The superior portion of the breast derives its sensation from the nerves of the cervical plexus; sensory innervation to the medial skin and inframammary gland is provided by the anterior cutaneous branches of the second through seventh intercostal nerves.

References
1. Bostwick J, ed. Plastic and Reconstructive Breast Surgery. Saint Louis, Mo: Quality Medical Publishing, Inc; 1990:95-96.
2. Lejour M. Applied anatomy for vertical mammaplasty. In: Vertical Mammaplasty and Liposuction. Saint Louis, Mo: Quality Medical Publishing, Inc; 1994:53.