Inservice Exam - 2005
Breast Reduction

On the basis of evaluation of cutaneous light-pressure thresholds of the breast with Semmes-Weinstein monofilaments, which of the following areas of the breast is most sensitive?

(A) Areola
(B) Inferior quadrants
(C) Nipple
(D) Superior quadrants

The correct response is Option D.

Based on the evaluation of cutaneous light-pressure thresholds with the Semmes-Weinstein monofilaments, there are marked differences in sensory perception between the skin of the breast, the areola, and the nipple. Irrespective of breast size, the skin in the superior quadrant is the most sensitive part of the breast, the areola is less sensitive, and the nipple is the least sensitive part to light pressure. The fact that the nipple is the least sensitive area in the female breast is thought to allow the mother to nurse without discomfort. Vibration is most sensitive in the areola.
Larger breasts are significantly less sensitive than smaller breasts in all anatomic areas, and there is a significant decrease of sensibility with increasing breast ptosis. Sensitivity tends to decrease with age.

References:
1. Tairych GV, Kuzbari R, Rigel S, et al. Normal cutaneous sensibility of the breast. Plast Reconstr Surg. 1998;102(3):701-704.
2. Courtiss EH, Goldwyn RM. Breast sensation before and after plastic surgery. Plast Reconstr Surg. 1976;58:1-13.
3. Slezak S, Dellon AL. Quantitation of sensibility in gigantomastia and alteration following reduction mammaplasty. Plast Reconstr Surg. 1993;91:1265-1269.



A 15-year-old girl has a one-year history of asymmetric enlargement of the left breast. Physical examination shows a 10-cm mass as well as ptosis, marked stretching of the nipple-areola complex, skin ulceration superolateral to the nipple, and presence of a prominent, dilated vein. Mammography and ultrasonography show a dense, circumscribed, homogeneous mass occupying the entire breast. Which of the following is the most appropriate management?

(A) Enucleation of the mass
(B) Hormone therapy
(C) Lumpectomy and postoperative radiation therapy
(D) Reduction mammaplasty
(E) Total mastectomy and reconstruction


The correct response is Option A.


This patient has giant fibroadenoma, which is best managed by enucleation of the mass. A large breast lesion in a female adolescent may result from giant fibroadenoma, phyllodes tumor, and juvenile breast hypertrophy. Fibroadenoma is the most common breast neoplasm in adolescents; giant fibroadenoma is characterized by a lesion larger than 5 cm in diameter, presentation at or soon after puberty, and a short doubling time. Usually, the lesion is solitary, firm, and nontender and causes rapid, asymmetric enlargement of the breast, prominent overlying veins, and occasionally skin ulceration caused by pressure. Giant fibroadenomas are benign lesions that can be excised by enucleation with minimal risk of recurrence. They do not require mammaplasty, lumpectomy, mastectomy, or hormone or radiation therapy.


Phyllodes tumors are large, benign tumors that occur primarily in perimenopausal patients. They are histologically distinct from giant fibroadenomas and rarely affect adolescents. They are treated with local excision or mastectomy.

Juvenile breast hypertrophy is a rare but well-described disorder in young girls early in puberty. It presents as diffuse enlargement of the breast without nodules or discrete masses. It is treated by reduction mammaplasty.


References:
1. McGrath MH. Benign tumors of the teenage breast. Plast Reconstr Surg. 2000;105:218-222.
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. Vol. 1. Philadelphia: WB Saunders; 1991:715-729.
3. Rohrich RJ, Thornton JF, Sorokin ES. Recurrent mammary hyperplasia: current concepts. Plast Reconstr Surg. 2003;111:387-393.



A 20-year-old woman who comes to the office for consultation regarding reduction mammaplasty inquires about ability to breast-feed after surgery. The most appropriate response to this patient is that breast-feeding is possible after each of the following techniques EXCEPT

(A) free nipple
(B) inferior pedicle
(C) liposuction
(D) McKissock bipedicle
(E) vertical

The correct response is Option A.

In the reduction mammaplasty technique using free nipple grafting, the nipple is totally removed from the breast and placed as a skin graft in a new, superior location. Therefore, lactation is no longer possible because the milk ducts are no longer connected to the nipple.

If suction lipectomy or pedicled techniques are used, breast tissue is preserved behind the nipple and the collecting ducts are still attached to the nipple; therefore, lactation is possible. Even with these techniques, the success of breast-feeding still varies with societal influences, patient desires, amount of tissue resected, and hormonal production of engorgement and milk.

In one study of 78 patients having babies after reduction, 29% breast-fed their children, 18% attempted breast-feeding and were unsuccessful, and 52% did not wish to breast-feed. In a study of 49 Brazilian women who had undergone reduction mammaplasty (breast-feeding is more common in Brazil), 58% breast-fed compared with 94% of nonoperated control subjects. The length of time that children were breast-fed was shorter in the reduction mammaplasty patients. In a third study of 30 women, 93% wished to breast-feed and were successful, although many of the babies required complementary formula feedings.

References:
1. Harris L, Morris SF, Freiburg A. Is breast feeding possible after reduction mammaplasty? Plast Reconstr Surg. 1992;89(5):836-839.
2. Souto GC, Giugliani ER, Giugliani C, et al. The impact of breast reduction on breastfeeding performance. J Hum Lact. 2003;19(1):43-49.
3. Marshall DR, Callan PP, Nicholson W. Breastfeeding after reduction mammaplasty. Br J Plast Surg. 1994;47(3):167-169.