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Guseno JA, Coon D, Rubin JP. Pseudogynecomastia a ter massive weight loss: detectability o technique, patient satis action, and
classi cation. Plast Reconstr Surg. 2008;122(5):1301–1311.
Haeck PC, Swanson JA, Gutowski KA, et al. Evidence-based patient sa ety advisory: liposuction. Plast Reconstr Surg. 2009;124(Suppl):
28S–44S.
Hurwitz DJ, Agha-Mohammadi S, Ota K, Unadkat J. A clinical review o total body li t surgery. Aesthet Surg J. 2008;28(3):294–303.
Iverson RE, Lynch DJ; American Society o Plastic Surgeons Committee on Patient Sa ety. Practice advisory on liposuction. Plast
Reconstr Surg. 2004;113(5):1478–1490.
Iverson RE, Pao VS. MOC-PS(SM) CME article: liposuction. Plast Reconstr Surg. 2008;121(4 Suppl):1–11.
Keyes GR, Singer R, Iverson RE, et al. Mortality in outpatient surgery. Plast Reconstr Surg. 2008;122(1):245–250.
Klein JA. umescent technique or local anesthesia improves sa ety in large-volume liposuction. Plast Reconstr Surg. 1993;92(6):1085–
1098; discussion 1099–1100.
Knoetgen J III, Moran SL. Long-term outcomes and complications associated with brachioplasty: a retrospective review and cadaveric
study. Plast Reconstr Surg. 2006;117(7):2219–2223.
Krueger J, Rohrich RJ. Clearing the smoke: the scienti c rationale or tobacco abstention with plastic surgery. Plast Reconstr Surg.
2001;108(4):1063–1073.
Lockwood . Brachioplasty with super cial ascial system suspension. Plast Reconstr Surg. 1995;96:912–920.
Lockwood . Contouring o the arms, trunk, and thighs. In: Achauer BM, Eriksson E, Guyuron B, et al., eds. Plastic Surgery: Indications,
Operations, and Outcomes. Vol 5. St Louis, MO: Mosby-Year Book, Inc; 2000:2839–2857.
Lockwood . Lower body li t with super cial ascial system suspension. Plast Reconstr Surg. 1993;92:1112–1125.
Matarasso A. Abdominoplasty. In: Achauer BM, Eriksson E, Guyuron B, et al., eds. Plastic Surgery: Indications, Operations, and Outcomes.
Vol 5. St Louis, MO: Mosby-Year Book; 2000:2783–2821.
Matarasso A. Liposuction as an adjunct to a ull abdominoplasty. Plast Reconstr Surg. 1995;5:829–836.
Matarasso A, P ei er M; Plastic Surgery Educational Foundation DA A Committee. Mesotherapy or body contouring. Plast Reconstr
Surg. 2005;115(5):1420–1424.
Melling AC, Ali B, Scott EM, Leaper DJ. E ects o preoperative warming on the incidence o wound in ection a ter clean surgery: a
randomized controlled trial. Lancet. 2001;358(9285):876–880.
Mentz HA. Fat emboli syndromes ollowing liposuction. Aesthetic Plast Surg. 2008;32(5):737–738.
Park SH, Kim DW, Lee MA, et al. E ectiveness o mesotherapy on body contouring. Plast Reconstr Surg. 2008;121(4):179e–185e.
Rohrich RJ, Leedy JE, Swamy R, et al. Fluid resuscitation in liposuction: a retrospective review o 89 consecutive patients. Plast Reconstr
Surg. 2006;117(2):431–435.
Rohrich RJ, Smith PD, Marcantonio DR, Kenkel JM. T e zones o adherence: role in minimizing and preventing contour de ormities
in liposuction. Plast Reconstr Surg. 2001;107(6):1562–1569.
Rubin JP, Guseno JA, Coon D. Dermal suspension and parenchymal reshaping mastopexy a ter massive weight loss: statistical analysis
with concomitant procedures rom a prospective registry. Plast Reconstr Surg. 2009;123(3):782–789.
Sebastian JL. Bariatric surgery and work-up o the massive weight loss patient. Clin Plast Surg. 2008;35(1):11–26.
Shermak MA, Chang D, Magnuson H, Schweitzer MA. An outcomes analysis o patients undergoing body contouring surgery a ter
massive weight loss. Plast Reconstr Surg. 2006;118(4):1026–1031.
Siana JE, Rex S, Gottrup F. T e e ect o cigarette smoking on wound healing. Scand J Plast Reconstr Surg Hand Surg. 1989;23(3):
207–209.
Stephan PJ, Kenkel JM. Updates and advances in liposuction. Aesthet Surg J. 2010;30(1):83–97.
Swanson E. Prospective outcome study o 360 patients treated with liposuction, lipoabdominoplasty, and abdominoplasty. Plast Reconstr
Surg. 2012;129(4):965–978.
Vogt P. Body contouring: upper extremity. In: Mathes SJ, ed. Plastic Surgery. Philadelphia, PA: Elsevier; 2006;6:291–314.
Wang HD, Zheng JH, Deng CL, Liu QY, Yang SL. Fat embolism syndromes ollowing liposuction. Aesthetic Plast Surg. 2008;32(5):
731–736.
Zocchi ME. Ultrasonic assisted lipoplasty: technical re nements and clinical evaluations. Clin Plast Surg. 1996; 23:575–598.

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125
Nicholas A. Flugstad, MD and
Joseph P. Hunstad, MD, FACS

What was the most common cosmetic surgical procedure per ormed in the United States in 2014?
Liposuction (Cosmetic Surgery National Data Bank Statistics, 2014).

How many cases o cosmetic liposuction were per ormed in 2014?
342,494 (Cosmetic Surgery National Data Bank Statistics, 2014).

What is the emale gynoid pattern o at distribution?
Women typically accumulate at in the lower trunk, hips, upper thighs, and buttocks.

What is the male android pattern o at distribution?
Men typically accumulate at in the trunk, with increased abdominal girth, thickened torso, upper abdomen, and nape.

Do men or women have a higher percentage o total body at?
1. Women
2. Based on body type, percentage o body at or the adult is as ollows:
Suction Lipectomy
CHAPTER 16
Body Type

Wom en

Men
Athlete

<17

<10
Lean

17–22

10–15
Normal

22–25

15–18
Above average

25–29

18–20
Overweight

29–35

20–25
Obese

>35

>25

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Plastic & Reconstructive Surgery Board Review

Describe the anatomic at layers in the torso and proximal lower extremity.
1. Super cial adipose layer:
• Made up o compact, dense pockets o at contained within well-organized brous septa. Changes little with
weight gain.
2. Deep adipose layer:
• Consists o looser, more areolar at bound by less organized partitions. Expands with weight gain.
• T e super cial ascia system separates the two layers.

What are the three “surgical” at layers?
1. Deep
2. Intermediate
3. Super cial

Suction o which at layer creates the greatest risk or contour de ormity?
Super cial layer.

What are the ve zones o adherence that should be avoided during liposuction?
1. Lateral gluteal depression
2. Gluteal crease
3. Distal posterior thigh
4. Mid medial thigh
5. In erolateral iliotibial tract

What is cellulite?
• AKA gynoid lipodystrophy
• Re ers to the dimpling o the skin in the buttocks and lower extremities
• Most o ten seen in women

What is the cause o cellulite?
Multi actorial, including hypertrophy o super cial adipocytes, brous dermal septae, dermal laxity.

Is there an FDA-approved surgical treatment or cellulite?
1. Subdermal treatment with 1,440 nm Nd:YAG side ring laser (Cellulaze, Cynosure, Inc.) Liposuction alone is
not a recommended treatment.
2. Cell na (Merz, Inc.). Mechanical release o brous septae attachments to the dermis.

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127

What is the dry technique or liposuction? Is it currently in clinical practice?
1. Suction lipectomy per ormed without in ltrate.
2. It is currently not in practice due to excessive blood loss, 30% to 46% o total aspirate.

What is the wet technique or liposuction?
1. echnique initially described by Illouz using 100–300 cc o in ltrate or each area to be suctioned, regardless o
volume o aspirate.
2. Estimated blood loss with this technique is 20% to 25% o total aspirate.

What is the superwet technique?
1. Injection o dilute solution o local anesthetic and epinephrine, with 1 cc in ltrate or every 1 cc at aspirate
(1:1 ratio).
2. Blood loss with this technique averages 1% to 4% o total aspirate.

What is the tumescent technique?
1. In ltration o large volumes o dilute solution containing local anesthetic with epinephrine, with estimated
ratio o in ltrate to aspirate o 3:1.
2. Blood loss with this technique is estimated to be 1% o total aspirate.

What is the end point o tumescent in ltration?
Skin turgor or peau d’orange appearance.

Approximately what percentage o in ltrated solution is removed by liposuction?
20%.

What is the recommended concentration o epinephrine in tumescent solution?
1:1,000,000.

What is a common ormulation o tumescent solution (Hunstad Solution)?
1. 1 L o Ringer’s lactate solution at 38 to 40°C
2. 50 mL o 1% lidocaine (= 500 mg)
3. 1 mL o 1:1,000 epinephrine
T is provides a solution that is 1:1,000,000 epinephrine and 0.05% lidocaine. T e lidocaine is decreased to 25 or
12.5 mL 1% lidocaine or in ltrates greater than 5 L.
(Klein solution: replace Ringer’s lactate with normal saline, and may add sodium bicarbonate.)

What is considered the maximum sa e dose o lidocaine in in ltration?
35 mg/kg.

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Why is this dose so much higher than that recommended with local anesthesia?
1. Dilute solution o lidocaine.
2. Use o epinephrine that slows the lidocaine rate o absorption.
3. Aspiration o injectate reduces the lidocaine load.
4. Absorption o solution rom adipose tissue is slow due to the relative lack o vascularity.

What systemic levels o lidocaine are associated with physical ndings?
1. 3 to 6 µg/mL: circumoral numbness, tinnitus, drowsiness
2. 5 to 9 µg/mL: shivering, twitching, tremors
3. 8 to 12 µg/mL: seizures, central nervous system depression
4. 20 µg/mL: respiratory arrest
5. 26 µg/mL: cardiac arrest

When do lidocaine levels peak?
Serum lidocaine levels peak 10 to 14 hours a ter in ltration.

What are some techniques to prevent lidocaine toxicity in liposuction?
1. Decrease the amount o lidocaine in in ltration solution.
2. Use smaller volumes o in ltrate by applying superwet rather than tumescent technique.

How is lidocaine toxicity treated?
In patients under general anesthesia, the rst noted symptoms are o ten cardiac. reatment involves airway
management, respiratory, and circulatory support. Benzodiazepines may be used to treat seizures. Administration
o lipid emulsion (intralipid) may be bene cial.

What are some o the bene ts o syringe versus vacuum aspiration?
1. More accurate at removal
2. Decreased blood loss
3. Accelerated patient recovery

What is power-assisted liposuction (PAL)?
PAL uses rapidly oscillating cannula that promotes at removal.

What are some uses or PAL?
It reduces surgeon atigue and is good or brous areas o at, gynecomastia surgery, secondary surgery.

What are the primary endpoints or PAL and standard liposuction?
Final contour, symmetric pinch test results.

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129

What is ultrasonic-assisted liposuction (UAL)?
UAL uses a handpiece that converts electrical energy to ultrasonic energy. T is energy is transmitted to the at
tissue through an oscillating probe. T is has a cavitation e ect on adipocytes, which subsequently implode. T e
emulsi ed at is then evacuated with greater ease.

What are the three stages o UAL?
Stage 1: Subcutaneous in ltration
Stage 2: Ultrasound treatment to emulsi y at
Stage 3: Evacuation o emulsi ed at and nal contouring

What are the primary end points o UAL?
1. Loss o tissue resistance
2. Blood in aspirate

What are the secondary end points o UAL?
1. reatment time relative to amount o in ltrated tumescent solution
2. reatment volume

What is one complication speci c to UAL?
T ermal injury.

What is the VASER system?
A system or UAL that emits pulsed energy as opposed to continuous energy. T is decreases the risk or thermal
injury.

What is the de nition o large-volume liposuction?
Lipoaspirate volume greater than 5,000 mL.

Which states have imposed regulations on lipoaspirate volume?
Cali ornia, Florida, Kentucky, New York, Ohio, ennessee.

What is the recommended f uid replacement when per orming large-volume liposuction?
Maintenance intravenous uid or the rst 5 L o aspirate, and replacement o urther losses with 0.25 mL IV or
every 1 mL aspirated over 5 L (when superwet technique is used).

What are the sa ety guidelines recommended by the ASPS or large-volume liposuction?
Selection o ASA 1 patients within 30% o ideal body weight, overnight care or monitoring o uid status, use o
SCDs, use o less than 35 mg/kg o lidocaine in ltration.

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How long should compression garments be worn a ter liposuction?
ypically or 2 weeks they are worn 24 hours per day except or showering. A ter that they are worn during the
day or another 4 to 6 weeks.

What is the most common complication a ter liposuction?
Contour irregularity—seen in approximately 9.2% o cases.

What is the recommended treatment or a contour irregularity ollowing liposuction?
1. Conservative treatment, including massage, should be used or 6 months.
2. A ter 6 months, surgical correction can be per ormed by liposuction around the area o depression, or by at
gra ting the depression itsel .

What techniques can help prevent contour de ormity rom liposuction?
1. Use o small cannulas
2. Cross-tunneling with multiple incisions
3. Avoid treatment o super cial at layer
4. Use o at separation technique be ore suctioning and at equalization technique a ter suctioning

Describe the classic triad o at embolism syndrome.
Altered mental status, petechial rash, respiratory distress.

What are the major predisposing conditions or at embolism syndrome?
raumatic long bone ractures, orthopedic surgery, so t tissue injury, liposuction.

What is the overall mortality rate rom liposuction?
1. Liposuction alone: 0.002% (1 in 47,415)
2. Liposuction with other procedures, excluding abdominoplasty: 0.0137% (1 in 7,314)
3. Liposuction with abdominoplasty, with or without other procedures: 0.03% (1 in 3,281)

According to Hughes, what are the reported complication rates rom liposuction?
1. Skin slough: 0.09% (1 in 1,107 procedures)
2. UAL thermal injury: 0.07% (1 in 1,404 procedures)
3. Deep vein thrombosis: 0.03% (1 in 3,040 procedures)
4. Pulmonary embolus: 0.026% (1 in 3,759 procedures)
5. Excessive blood loss: 0.015% (1 in 6,711 procedures)
6. Fluid overload: 0.014% (1 in 7,246 procedures)
7. Fat embolus: 0.005% (1 in 18,868 procedures)
8. Abdominal cavity penetration: 0.002% (1 in 47,619 procedures)
9. Lidocaine toxicity: 0.002% (1 in 47,619 procedures)

CHAPTER 16 Suction Lipectomy
131
REFERENCES
American Society or Aesthetic Plastic Surgery. Cosmetic Surgery National Data Bank Statistics; 2014.
DiBernardo BE. reatment o cellulite using a 1440-nm pulsed laser with one year ollow-up. Aesthet Surg J. 2011;31(3):328–341.
Gasperoni C, Gasperoni P. Subdermal liposuction: long-term experience. Clin Plast Surg. 2006;33:63–73.
Haeck PC, Swanson JA, Gutowski KA, et al. Evidence-based patient sa ety advisory: liposuction. Plast Reconstr Surg 2009;124(suppl):
28S–44S.
Hetter GP. Blood and uid replacement or lipoplasty procedures. Clin Plast Surg. 1989; 16:245–248.
Hetter GP. T e e ect o low-dose epinephrine on the hematocrit drop ollowing lipolysis. Aesthetic Plast Surg. 1984;8:19–21.
Hughes CE. Reduction o lipoplasty risks and mortality: an ASAPS survey. Aesthetic Surg J. 2001;21:120–127.
Hunstad JP, Aitken ME. Liposuction and tumescent surgery. Clin Plast Surg. 2006;33:39–46.
Hunstad JP. Addressing dif cult areas in body contouring with emphasis on combined tumescent and syringe techniques. Clin Plast
Surg. 1996;23(1):57–80.
Illouz YG. Body contouring and lipolysis: a 5-year experience with over 3000 cases. Plast Reconst Surg. 1983;72:591–597.
Illouz YG. Complications o liposuction. Clin Plast Surg. 2006;33:129–163.
Illouz YG. Illouz’s technique o body contouring by lipolysis. Clin Plast Surg. 1984;11:409–417.
Illouz YG. Study o subcutaneous at. Aesthetic Plast Surg. 1990;14:165–177.
Klein JA. Deaths related to liposuction. N Engl J Med. 1999;341(13):1001–1002.
Klein JA. umescent technique or local anesthesia improves sa ety in large-volume liposuction. Plast Reconstr Surg. 1993;92:1085–1098.
Klein JA. umescent technique or regional anesthesia permits lidocaine doses o 35 mg/kg or liposuction. J Dermatol Surg Oncol.
1990;16:248–263.
Matarasso A, Kim RW, Kral JG. T e impact o liposuction on body at. Plast Reconstr Surg. 1998;102:1686–1689.
Neal JM, Bernards CM, Butterworth IV JF, et al. ASRA practice advisory on local anesthetic systemic toxicity. Reg Anesth Pain Med.
2010;35:152–161.
Pitanguy I. Abdominal lipectomy. Clin Plast Surg. 1975;2:401–410.
Rohrich RJ, Leedy JE, Swamy R, Brown SA, Coleman J. Fluid resuscitation in liposuction: a retrospective review o 89 consecutive
patients. Plast Reconstr Surg. 2006;117:431–435.
Rohrich RJ, Raniere J Jr, Beran SJ, Kenkel JM. Patient evaluation and indications or ultrasound-assisted lipoplasty. Clin Plast Surg.
1999;26(2):269–278.
Rohrich RJ, Raniere J Jr, Kenkel JM, Beran SJ. Operative principles or optimizing results in circum erential body contouring with
ultrasound-assisted lipoplasty. Clin Plast Surg. 1999;26(2):305–316.
Rohrich RJ, Smith PD, Marcantonio DR, Kenkel JM. T e zones o adherence: role in minimizing and preventing contour de ormities
in liposuction. Plast Reconstr Surg. 2001;107(6):1562–1569.
Rossi AM, Katz BE. A modern approach to the treatment o cellulite. Dermatol Clin. 2014;32:51–59.
Wall S Jr. SAFE circume erential liposuction with abdominoplasty. Clin Plast Surg. 2010;37(3):485–501.
Wang HD, Zheng JH, Deng CL, Liu QY, Yang SL. Fat embolism syndromes ollowing liposuction. Aesthetic Plast Surg. 2008;32(5):
731–736.
Zocchi M. Ultrasound-assisted lipectomy. Adv Plast Reconstr Surg. 1995;11:197.

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Section II BREAST

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135
Alvin B. Cohn, MD and
Jayant P. Agarwal, MD

What is the smallest unctional unit o the breast?
Acini cell.

When do the mammary ridges develop in an embryo?
Fi th or sixth week o gestation.

What is the path o the mammary ridge along the ventral aspect o an embryo?
Base o the orelimb ( uture axilla) to the base o the hindlimb (inguinal area).

What is the result o incomplete involution o the mammary ridge?
Accessory breast tissue and supernumerary nipples.

What is the di erence between accessory and ectopic breast tissue?
Accessory breast tissue occurs in the mammary line rom axilla to groin, whereas ectopic breast tissue can occur
anywhere outside the mammary line.

What is polymastia?
Accessory breast tissue, usually ound in axilla.

What is polythelia?
Accessory nipples that can develop anywhere along the milk line.

Which is more common polymastia or polythelia?
Polythelia.
Breast Anatomy/
Embryology
CHAPTER 17

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Plastic & Reconstructive Surgery Board Review

What is amazia?
Nipple development without breast tissue development.

What is athelia?
Breast development without nipple development.

Is amastia more commonly unilateral or bilateral?
Unilateral.

What is the cause o unilateral amastia?
Arrested mammary ridge development during the sixth week o etal development.

Where is the most common site o aberrant breast tissue?
Axilla.

Which is more concerning: unilateral or bilateral inverted nipples?
Unilateral; bilateral is usually an associated benign congenital condition. Unilateral is more o ten associated with
pathologic ndings such as cancer.

Where is the most common site o a supernumerary nipple?
In ramammary area.

T e breast overlies which ribs?
Second to sixth.

Each cluster o alveoli leads to a milk duct that empties into a lacti erous sinus. Each lacti erous sinus drains
one lobe o the breast. How many lobes are in the breast?
15 to 25 lobes per breast.

What is the di erence between a breast lobule and a breast lobe?
Lobes consist o multiple lobules and their respective interlobular ducts. Lobules are composed o glandular tissue
containing acini cells that produce milk.

Which quadrant o the breast contains the most glandular tissue?
Upper outer quadrant.

What is the most common bacteria cultured rom breast tissue?
Staphylococcus epidermidis.

CHAPTER 17 Breast Anatomy/Embryology
137

Which vessel provides the dominant blood supply to the breast?
Internal mammary artery.

T e internal mammary artery is a branch o which artery?
Subclavian artery (le t)/brachiocephalic artery (right).

Usually, what vessel is the largest artery entering the pectoralis major muscle and overlying breast
parenchyma?
T e second intercostal internal mammary per orator.

Name three branches o the axillary artery ( rom medial to lateral) that serve as blood supply to the breast.
T oracoacromial, lateral thoracic, and thoracodorsal arteries.

When dissecting the axilla, i you clip the intercostobrachial nerve, where will you lose sensation?
Upper medial aspect o arm and axilla.

T e intercostobrachial nerve is a branch o what nerve?
Lateral branch o the second intercostal nerve.

Axillary nodes are noted as level I, level II, or level III. What anatomic structure determines their “level”?
Pectoralis minor muscle.

Where are level I axillary lymph nodes located?
Lateral/below the lower border o pectoralis minor.

Where are level II axillary lymph nodes located?
Behind pectoralis minor.

Where are level III axillary lymph nodes located?
Medial/above the upper border o pectoralis minor.

Where is a Rotter’s lymph node located?
Interpectoral node.

What is the primary innervation to the nipple–areola complex?
Lateral branch o the ourth intercostal nerve.

What is the course o the lateral branch o the ourth intercostal nerve?
It pierces the deep ascia in the midaxillary line and takes an in eromedial course within the pectoral ascia.
On reaching the midclavicular line, it turns 90 degrees and continues through the glandular tissue toward the
posterior sur ace o the nipple.

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Plastic & Reconstructive Surgery Board Review

What is the normal diameter o the areola complex?
35 to 45 mm.

What is the dominant blood supply to the NAC?
Per orators rom the internal mammary artery.

What is the unction o the Montgomery glands?
T ey are sebaceous glands that produce a waxy substance to assist with lubrication and protection o the nipple–
areola complex.

What ligaments provide support to the breast via connections rom the pectoralis ascia to the skin?
Cooper’s ligaments.

T e suspensory ligaments o Cooper attach which structures?
Deep pectoralis ascia to the dermis o the breast.

What is the lateral margin o the breast parenchyma?
Lateral margin o the latissimus dorsi.

What is the superior margin o the breast parenchyma?
T e clavicle.

What is the medial margin o the breast parenchyma?
Lateral sternum.

What is the major component o the anterior axillary old?
Pectoralis major.

What is the origin o the pectoralis major muscle?
Medial sternal hal o the clavicle and lateral aspect o the sternum/costochondral region, rom the sternal notch
down to the sixth or seventh costal cartilage.

T e insertion o the pectoralis major tendon lies between which two muscles?
Coracobrachialis (posterior) and deltoid (anterior).

Which nerve provides motor innervation to the lateral and in erior pectoralis major muscle?
Medial pectoral nerve.

T e serratus anterior originates rom costal attachments o the anterolateral aspects o the f rst through the
eighth ribs. Where does this muscle insert?
Deep medial sur ace o the scapula.

CHAPTER 17 Breast Anatomy/Embryology
139

What is the innervation to the serratus anterior muscle?
Long thoracic nerve.

What is the clinical mani estation o injury to the long thoracic nerve?
Winged scapula.

How can one locate the long thoracic nerve?
Positioned laterally, super cial to the external sur ace o the serratus anterior muscle in the midaxillary line.

I the thoracodorsal artery is proximally occluded/ligated, which vessel is capable o providing a signif cant
portion o blood supply to the latissimus dorsi?
Serratus branch o the thoracodorsal artery.

Which nerves supply innervation to the medial breast?
T e second to sixth medial intercostal nerves.

Which condition is associated with a congenital absence o the pectoralis major muscle, usually the sternal
component, as well as breast and areolar hypoplasia?
Poland syndrome.

Following e erent lymphatic drainage into the deep pectoral nodes and subscapular nodes, which nodes are
next in the lymphatic drainage pathway o the breast?
Central axillary nodes and apical axillary nodes.

Following e erent drainage into the axillary nodes, which nodes are next in the lymphatic drainage pathway
o the breast?
Supraclavicular nodes.

I lymphatic drainage takes a medial pathway (vs. draining into the axilla), which nodes are the primary
drainage basin?
Internal mammary nodes/parasternal nodes.

rue/False: Axillary nodes primarily drain the lateral hal o the breast, while parasternal nodes drain medial
quadrants.
False: Dye f ow studies report that both the axillary and the parasternal lymphatic groups receive lymph rom all
quadrants o the breast.

What aspect o the breast parenchyma supplies lymph to the internal mammary/parasternal nodes?
T e entire gland.

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Plastic & Reconstructive Surgery Board Review

Which hormone is principally responsible or ductal development and maintenance o glandular elements
during the reproductive years?
Estrogen.

Which hormone is principally responsible or lobular development and di erentiation o epithelial cells?
Progesterone.

Which hormone stimulates the di erentiation o milk-producing cells and initiates the synthesis o milk
components?
Prolactin.

What is the name o the hormone produced by the pituitary gland that causes ductal contraction with
lactation?
Oxytocin.

What anner stage signif es adult breast and areolar development?
anner Stage 5.

In the youth ul, nonptotic breast, where should the NAC be located?
Above the in ramammary old (IMF).

In the youth ul, nonptotic breast, what is the normal distance between the sternal notch and the nipple?
17 to 21 cm.

In the youth ul, nonptotic breast what is the normal distance between the nipple and the IMF?
7 to 8 cm.

What is the average diameter o the nipple?
5 to 8 mm.

What is the average projection o the nipple?
5 mm.

What is the etiology o a congenital inverted nipple? What is its incidence?
Failure o the mammary pit to elevate above skin level during in ancy; 2% to 4%.

What is Poland syndrome?
Hypoplasia or absence o the ipsilateral breast, absence o the sternal head o the pectoralis major muscle, costal
cartilage and rib de ects, hypoplasia o subcutaneous tissues o the chest wall, and brachysyndactyly.

CHAPTER 17 Breast Anatomy/Embryology
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What is the anatomic abnormality with the tuberous breast de ormity?
NAC hypertrophy, constricted breast/lower pole, herniation o breast tissue into NAC.

What is the di erence between skin-sparing mastectomy and total skin-sparing mastectomy?
T e NAC is preserved with total skin-sparing mastectomy.
REFERENCES
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Schwartz: Principles of Surgery. 7th ed. USA: McGraw-Hill; 1999:533–600.
Bostwick J III (ed). Anatomy and physiology. In: Plastic and Reconstructive Breast Surgery. Vol 1. 2nd ed. St. Louis, MO: Quality Medical
Publishing; 2000:77–120.
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Plastic Surgery: Indications, Operations, and Outcomes. 1st ed. St. Louis, MO: Mosby; 2000:2743–2744.
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2000;105(3):905–909.

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Ginger Xu, MD and
Sumner A. Slavin, MD

Are breast implants associated with an increased risk or any particular orms o cancer? What is the likely
course compared to patients without breast implants?
Several reports have suggested an association between breast implants (saline and silicone) and anaplastic large cell
lymphoma (ALCL). Most cases o ALCL have been in textured implants, and tend to have a more indolent course
and more avorable prognosis.

What is the impact o augmentation mammoplasty with autologous at trans er on mammogram f ndings?
T e impact is still uncertain to date. Fat necrosis is common a ter at gra ting and appearance on mammogram
may range rom lipid cysts and di usely scattered calci cations to ndings suspicious or malignancy such as
clustered, branching microcalci cations or spiculated masses. T ese should be worked up and sometimes biopsied.

Are suspicious mammographic changes more likely to occur in breast reduction or breast augmentation with
autologous at trans er?
Breast reduction. In a blinded study, Rubin et al. ound that masses requiring biopsy and scarring were more
common in the reduction cohort than the at gra ting cohort.

When augmentation/mastopexy is per ormed or tuberous breast de ormity, what complication is more
likely to occur than in a patient without a tuberous breast?
Double bubble. T is will occur i the native in ramammary crease, which can be high and tight, does not ully
expand a ter release. Over time, the lower pole skin stretches in response to the implant and this double bubble
o ten improves spontaneously.

What actors are linked to a higher rate o reoperation in patients undergoing augmentation mammoplasty?
Pre-existing breast ptosis and simultaneous mastopexy. Furthermore, increasing grades o breast ptosis were linked
with increasingly higher reoperation rates.
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What is the correlation between incision site or augmentation mammoplasty and rate o capsular contracture?
IMF incisions have the lowest rate, while periareolar and transaxillary incisions have a 5 to 10 times higher rate o
capsule-related complications.

What is the main actor that can contribute to adverse outcomes with simultaneous augmentation
mammoplasty and mastopexy?
Large prosthesis (de ned as greater than 350 mL) leads to greater adverse e ects on vascularity and so t-tissue
attenuation.

What is double capsule phenomenon and with what type o implants does it more commonly occur?
Late-onset seroma without signs o in ection: a capsule layer is seen lining the pocket, which o ten contains a
substantial volume o serosanguineous seroma uid and a textured implant coated in a tight second capsule at the
center o the pocket. More common with textured implants.

What is the most important actor in determining the maximum acceptable prosthesis size or a patient?
Breast base width.

What is the main arterial blood supply to the breast gland and nipple during submuscular augmentation?
T oracoacromial; travels just deep to the pectoralis major muscle, supplying circulation to the overlying breast
tissue and skin. Subglandular dissection disrupts the connection between the thoracoacromial vessels and the
overlying breast, while submuscular dissection preserves it. Subglandular augmentation may be per ormed though
capsular contracture rates may di er.

What is the appropriate intervention or implants appearing “too high” soon a ter augmentation?
Breast massage and breast band application. Breast shape ollowing augmentation mammoplasty undergoes
dynamic changes, as the skin envelope and pectoralis muscle stretch under the expansion pressure o the
prosthesis.

What is the most common complication a ter cohesive silicone gel breast prostheses or “gummy bear”
implants?
Capsular contracture (Baker III/IV): 9.8% or aesthetics and 13.7% or reconstructive procedures at 6 years.
Rupture rate was 1.1%/3.8% and in ection was 1.6/6.1%, respectively.

What actors are associated with increased risk o rippling o breast implants?
extured implants (over two old increase in one study), saline implants, subglandular placement, thin native breast
tissue, ptosis.

What are the disadvantages o an augmentation per ormed in the subglandular plane as compared with
subpectoral? What are the advantages?
Disadvantages: higher rate o capsular contracture, less satis actory or mammography, and a higher risk o
visibility, palpability, and a sharp transition in the upper pole.
Advantages: the subglandular plane allows increased control o in ramammary old position and shape and has
little or no implant distortion with pectoralis contraction.

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In which patients should subpectoral implantation be used with caution? Why?
Patients with signi cant postpartum atrophy, glandular ptosis, and signi cant native tissue volume loss. Higher
risk o double-bubble de ormity.

What is the signif cance o the “pinch test” or subglandular augmentation?
A minimum pinch test o 2 cm is recommended in the superior pole or adequate so t-tissue thickness to
cover a subglandular implant. So t-tissue thickness less than 2 cm increases risk o rippling and wrinkling with
subglandular placement and thus, submuscular placement is recommended.

What is a “dual plane” augmentation?
A variation o the subpectoral augmentation designed to reduce the risk o double-bubble de ormity. Subpectoral
dissection is combined with a partial subglandular dissection that extends a variable distance above the in erior
border o the pectoralis major muscle.

What is the most common complication o breast augmentation?
Capsular contracture, with rates reported between 0.5% and 30%.

What should the implant pocket be irrigated with to decrease the incidence o in ection and capsular
contracture?
Mixture o 50,000 U Bacitracin, 1 g ce azolin, 80 mg gentamicin, and 500 mL saline.

What is the rate o grade III/IV capsular contracture or primary breast augmentation with silicone implants
at 6-year ollow-up (Mentor, Inamed)? Rate or revision augmentation?
Mentor and Inamed published their 6-year data or gel implants and show contracture rates (grade III/IV) o 20%
to 28% a ter primary augmentation and 34% to 40% a ter revision augmentation.

What is the capsular contracture rate (grade III/IV) or saline implants at 13-year ollow-up?
Approximately 21%.

What is the main advantage o textured implants?
Implant-sur ace texturing reduces the contracture rate or subglandular prostheses.
No such advantage is seen in the submuscular position.

Compare contracture, leakage, and wrinkling rates between saline and silicone implants and what is the
primary advantage o saline implants?
Both implants produce contractures, wrinkling, and leakage at similar rates. Rupture is easier to detect in saline
implants.

What actors should be evaluated prior to per orming an augmentation that can help to choose the proper
implant size, reduce the reoperation rate, and produce a more predictable outcome?
Base width (BW), nipple to IMF distance (N:IMF), so t-tissue pinch thickness o the upper pole, and the anterior
pull skin stretch.

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In which patients should the periareolar incision be used with caution?
Patients with small areolar diameters (< 3 cm), and patients with areolas that are lightly colored with indistinct
margins.

In which patients should the in ramammary incision be used with caution?
Patients with poorly de ned in ramammary olds, constricted breasts, or an in ramammary old too close to the
areola.

Where are the disadvantages o a transaxillary approach?
Less control and accuracy as compared with a more direct approach, theoretically increasing the risk o implant
malposition or asymmetry. Dif cult or impossible with silicone implants. Risk o injury to sensory nerves branches
o the intercostobrachial and medial brachial cutaneous nerves during dissection o axillary at causing numbness
o the medial arm.

In which patients should the transaxillary approach not be used?
Patients with tuberous breast de ormity, patients requiring parenchymal rearrangement, or patients in whom an
anatomic or large silicone implant has been chosen.

What are the long-term changes seen in the breast tissue and chest wall in an augmented patient?
Breast parenchymal atrophy and costal cartilage remodeling that result in a concave shape o the ribs. All implants,
especially larger implants, will cause shrinkage and thinning o breast tissue.

What is the reported in ection rate a ter augmentation?
1% to 2.2%.

What is the most common aerobic pathogen? Anaerobic?
Staphylococcus aureus and Propionibacterium acnes.

What is the treatment o in ection a ter implant placement?
For super cial in ections not involving the periprosthetic space, oral or intravenous antibiotics without drainage
o the pocket can be used. For more severe in ections involving the implant pocket, management includes implant
removal, irrigation, capsule debridement, antibiotics, and reinsertion o the implant several months later.

On average, what is the reported rate o decreased nipple sensation?
15%, regardless o incision type.

What is the rupture rate o saline-f lled implants per year?
1% per year.

What is the reoperation rate or silicone implant-related complications during the f rst 6 years a ter primary
augmentation? A ter revision augmentation?
Approximately 20% to 25% a ter primary augmentation and 35% or revision augmentation.

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What actor increases the risk o rupture o saline-f lled implants?
Under lling the implant resulting in an implant old abnormality.

What is the most accurate imaging modality or evaluating implant integrity?
MRI. Linguine sign indicates intracapsular silicone prosthesis rupture and represents the prosthesis shell oating
in ree silicone gel.

According to the US FDA, what is the recommended schedule o MRI screening to detect silicone prosthesis
rupture?
3 years a ter surgery and then every 2 years.

What are the key characteristics o tuberous breast de ormity?
Herniation o the breast tissue into the nipple–areola complex with a cylindrical projection accompanied by a
relatively large areola, de ciency o the lower pole o the breast in both vertical and horizontal axes, hypoplasia,
and a constricted and high in ramammary old.

What is the primary treatment and augmentation incision type or tuberous breast de ormity?
Periareolar mastopexy with augmentation, radial-releasing incisions to allow expansion o the base o the breast,
areolar reduction, and lowering the IMF.

What is symmastia and what are the risk actors or synmastia a ter breast augmentation?
Symmastia is de ned as when the breast implant crosses the midline, even i it is only on one side. Risk actors
include use o large prostheses with large base diameters, multiple successive enlargement procedures, pre-existing
chest wall de ormities, and subpectoral implant positioning.
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151
Pieter G. L. Koolen, MD,
Emily M. Clarke-Pearson, MD, MEd, and
Samuel J. Lin, MD, MBA, FACS
Disclaimer: T e controversy regarding breast implants, particularly silicone gel-f lled implants, continues to be debated despite
many large studies that have ailed to show a signif cant systemic health risk in women who have these devices. T is is partially
due to small and poorly designed reports that made associations between breast implants and various systemic diseases. As such, the
questions and answers in this chapter are based on large well-designed studies, pooled data, and consensus statements by established
health organizations. It should be understood that in some cases, there may be contradictory opinions in the scientif c literature.
Unless otherwise noted, these questions apply to saline or silicone gel-f lled breast implants available without restrictions in the
United States in 2010.

What is the shell o currently available breast implants made rom?
A silicone elastomer.

What is the material on the inside o currently available breast implants?
1. Saline breast implants are lled at the time o surgery with sterile saline, ideally through a closed lling system.
2. Silicone gel- lled implants come pre lled with a silicone polymer.

What are the advantages and disadvantages o silicone gel- lled breast implants compared to saline breast
implants?
Silicone implants are considered to look and eel more natural than saline implants, particularly in women with
less breast tissue or in women undergoing breast reconstruction. Because o this, silicone implants can be used in a
subglandular position in most patients. However, silicone implants are more expensive and require a larger incision
or placement. Owing to current government regulation, silicone implants cannot be used or nonreconstructive
purposes in patients younger than 22 years.

What are the advantages and disadvantages o implants with a textured shell?
T e textured shell may decrease the rate o capsular contracture but may cause more rippling, have greater
palpability, and may be more likely to de ate or rupture.
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and Sa ety
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How do breast implants af ect breast visualization by mammograms?
Although breast implants obscure some breast tissue when being visualized by mammograms, particularly implants
that are subglandular as opposed to submuscular, the overall rate o breast cancer detection is not a ected.

What kind o modi cation o standard mammography should be done or women with breast implants?
Women with breast implants should have mammograms with Eklund displacement views to visualize the breast
tissue adequately.
Eklund views add to the standard craniocaudal (CC) and mediolateral oblique (MLO) views by per orming two
additional CC and MLO views, and an optional th 90-degree lateral view, in which the implant is pushed back
against the chest wall and the breast tissue pulled orward. However, the additional views result in more radiation
exposure and may increase the risk o implant rupture due to the additional compression.

What are the conclusions o the Institute o Medicine’s report with regard to the toxicology o breast implant
material?
On the basis o toxicology studies o silicones and other substances in breast implants, there is no evidence or
health concerns.

What are the conclusions o the Institute o Medicine’s report with regard to the surgical complications
associated with silicone breast implants?
T e reoperations and local and perioperative complications are requent enough to be a cause or concern and to
justi y the conclusion that they are the primary sa ety issue with silicone breast implants. Complications may have
risks themselves, such as pain, dis gurement, and serious in ection, and they may lead to medical and surgical
interventions, such as reoperations, that have risks. An explanation o the risks is an essential element o adequate
in ormed consent or women undergoing breast implantation.

What are the conclusions o the Institute o Medicine’s report with regard to connective tissue diseases
associated with silicone breast implants?
On the basis o epidemiological evidence, connective tissue diseases or conditions, neurological diseases or other
systemic complaints or conditions are no more common in women with breast implants than in women without
implants.

What are the conclusions o the Institute o Medicine’s report regarding the ef ects o breast implants on
breast milk and health ef ects in children related to maternal breast implants?
T ere is no evidence o elevated silicone in breast milk or any other substance that would be deleterious to in ants.
All mothers with implants should attempt breast- eeding.

Based on the conclusions o the Institute o Medicine’s report, what is the evidence or a syndrome or disease
associated with silicone implants?
T ere is no evidence suggesting a new syndrome or disease in women with breast implants.

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What is the signi cance o the National Cancer Institute (NCI) Breast Implant Study?
T e NCI study is one o the longest and largest studies on the health e ects o silicone gel- lled breast implants
and involves 13,500 women with an average ollow-up time o 13 years. Unlike other studies that used only the
general population as a comparison group, the NCI study compared the health risks o the implant patients to
both the general population and the other plastic surgery patients.

Based on the NCI Breast Implant Study, what is the relationship between breast implants and development
o breast cancer?
T e NCI study ound no link between breast cancer risk and any particular type o breast implant. However,
there was a shi t toward somewhat later detection o breast cancers among the implant patients compared to the
controls. Even though the di erences were not statistically signi cant, there were consistently smaller percentages
o in situ (early stage) cancers among the implant patients. However, there was no signi cant di erence in breast
cancer mortality between implant and comparison patients. T is nding has been con rmed by other large
epidemiological studies.

Based on the NCI Breast Implant Study, what is the relationship between breast implants and development
o nonbreast cancers?
Women with implants were not at increased risk or most cancers including stomach, large intestine, cervix,
uterus, ovary, bladder or thyroid, so t-tissue sarcomas, lymphoma, and multiple myeloma. However, the cancer
rates or brain and respiratory cancers were two to three times greater in the implant patients compared to other
plastic surgery patients (but only the rates o respiratory cancers reached statistical signi cance). T e signi cance o
the increased risks is not clear and it is possible that the higher risks observed or respiratory and brain cancers are
not related to exposure to silicone, but are due to either chance ndings or actors common to women who choose
to have implants.

Based on the NCI Breast Implant Study, do women with breast implants have a dif erence in causes o death
compared with women without implants?
Women with implants were not at increased risk or most causes o death compared with the control group. T e
exceptions were deaths rom suicide, and brain and respiratory cancers, but the signi cance o these increased risks
is not clear.
Implant patients were three times more likely to die rom respiratory tract cancer, two to three times more likely
to die rom brain cancer, and our to ve times more likely to die rom suicide than the comparison group; only
the rates or respiratory cancers reached statistical signi cance. It is possible that these higher risks are not related
to exposure to silicone, but are due to either chance ndings or actors common to women who choose to have
implants.

Based on the NCI Breast Implant Study, do women with breast implants have an increased risk
o developing connective tissue diseases?
Women with breast implants were not at an increased risk or connective tissue disorders when their records were
reviewed by two independent rheumatologists who did not know i the women had an implant or not.

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What is the health signi cance o extracapsular silicone gel breast implant rupture?
One FDA report ound an association between extracapsular silicone gel rupture and bromyalgia. T is was based
on a study o 344 women who were asked i they had a diagnosis o rheumatologic or connective tissue disorder.
T ese women subsequently had magnetic resonance imaging (MRI) to determine implant integrity
and determination o silicone gel leakage outside the breast implant capsule.
Women with MRI-diagnosed breast implant rupture were no more likely than women with intact implants to
report that they had either persistent symptoms or doctor-diagnosed illnesses that were listed. While women
with MRI-diagnosed extracapsular silicone gel were 2.8 times more likely to report that they had the so t-tissue
syndrome, bromyalgia. T e limitations o this study include the ollowing:
1. No distinction between women who developed bromyalgia be ore and a ter breast implant surgery.
2. T e women’s sel -reported diagnosis o bromyalgia was not con rmed by a medical examination.
T is study does not show cause and e ect, but a statistical association between extracapsular silicone and
bromyalgia.

What is the single best method to detect saline breast implant rupture?
Since saline breast implant rupture results in de ation o the implant and a loss o breast volume, a simple physical
examination o the breast (or more likely a patient’s own observation o her breasts) will detect a rupture and
subsequent de ation.

In discussion with a patient desiring breast augmentation with saline implants, what rate o implant rupture
should be disclosed?
Since saline breast implant de ation is easy to identi y (the breast losses volume over a ew days), de ation rates are
easier to calculate. T e de ation rate is 3% to 5% o implants at 3 years and 7% to 10% o implants at 10 years.

What is the single best method to detect silicone breast implant rupture?
Currently, MRI is the best method to assess silicone implant integrity and diagnosis o intra- or extracapsular
implant rupture. In some cases, implant rupture may be detected by mammography, breast ultrasound, or C
imaging but these modalities are less accurate.

What is the sensitivity o MRI compared to physical examination in detecting silicone breast implant
rupture?
MRI has a sensitivity o approximately 89% in detecting implant rupture, compared to approximately 30% or a
physical examination by an experienced plastic surgeon.

What is silent implant rupture?
Rupture o a silicone gel- lled breast implant without symptoms. T is is more common than a rupture with
symptoms.

What are the current government recommendations to detect silent implant rupture?
T e recommendations are or an MRI to be done 3 years a ter initial implant placement surgery and therea ter
every 2 years. T e cost o MRI screenings may or may not be covered by insurance and should be considered by
patients in making a decision regarding breast implants.

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What are the signs and symptoms o possible silicone implant rupture?
A silicone implant rupture may be suspected by the presence o a new lump, swelling, hardening, pain or
discom ort in the breast, or change in implant shape. I rupture is suspected, an MRI should be obtained.

In discussion with a patient desiring breast augmentation with silicone implants, what rate o implant
rupture should be disclosed?
1. T e two manu acturers o silicone gel implants sold in the United States each conducted a Core Study o their
products.
2. Based on Allergan’s Core Study using MRI to detect silent rupture, or primary augmentation patients the
implant rupture was 5.1% at 7 years. However, since each patient has two implants, the rate o patients having
implant rupture was 8.6% at 7 years. T ere ore, approximately 9 out o 100 women will have a rupture within
7 years o primary augmentation.
3. For Allergan’s NA RELLE silicone breast implants with an average implant age o 11 years, silent rupture was
approximately 8% o the implants and 15% o patients.
4. Based on Mentor’s Core Study using MRI in primary augmentation, the silent rupture rate was 0.5% through
3 years and or revision-augmentation the rate was 7.7% through 3 years. In cases with a rupture, hal were
intracapsular and the other hal were extracapsular.

What is capsular contracture?
Capsular contracture is abnormal scar tissue that orms in the normal tissue capsule around the implant and causes
tightness, compression, rmness, or pain.

How is capsular contracture classi ed?
Capsular contracture is graded into our levels based on its severity.
Baker grade I: the breast is normally so t and looks natural
Baker grade II: the breast is a little rm but looks normal
Baker grade III: the breast is rm and looks abnormal
Baker grade IV: the breast is hard, pain ul, and looks abnormal
Grades III and IV are considered severe and o ten require corrective surgery (capsulectomy).

What is the rate o capsular contracture in primary augmentation?
Based on Allergan Core Study and Mentor Core Study, the contracture rates (Baker III or IV) or primary breast
augmentation are as ollows:
1. Allergan: 16% at 7 years
2. Mentor: 8% at 3 years

What is the reoperation rate or women having a primary breast augmentation with silicone gel implants?
Based on Allergan Core Study and Mentor Core Study, the reoperation rates ( or any reason) or primary breast
augmentation are as ollows:
1. Allergan: 30% at 7 years
2. Mentor: 15% at 3 years.

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What is the most common reason or reoperation in women having a primary breast augmentation with
silicone gel implants?
Based on Allergan Core Study and Mentor Core Study, the reasons or reoperation in women with primary breast
augmentation are as ollows:
1. Allergan: capsular contracture was the most common reason or reoperation ollowed by implant malposition
and then breast ptosis.
2. Mentor: capsular contracture was the most common reason or reoperation ollowed by patient request or
change in implant size or style and then hematoma or seroma.

What is the dif erence between closed capsulotomy and open capsulotomy/capsulectomy?
A closed capsulotomy is a method to break apart the capsular contracture by direct manual pressure on the breast
by the surgeon. An open capsulotomy is a surgical procedure where the abnormal capsule is incised to “release” the
scar tissue while a capsulectomy involves surgical excision o the abnormal scar tissue.

When should closed capsulotomy be per ormed?
Direct manual pressure to break the scar tissue causing capsular contracture is not recommended as this may not
only rupture a silicone implant but also cause an extracapsular rupture. I the implant is already ruptured, the gel
may be orced in to the breast tissue.

I an intracapsular silicone breast implant rupture is diagnosed by MRI in an otherwise asymptomatic
woman, what advise should she be given?
A silicone implant with MRI-diagnosed rupture is considered a ailed medical device and should be removed.
However, the only study that ollowed women with ruptured implants suggests that in this case, implant removal
is not mandatory. T e patient needs to consider the costs and risks o removal or replacement o a ruptured
implant in the absence o any symptoms. I the implant is not removed, the patient should be ollowed clinically
or any signs or symptoms related to the implant rupture.
REFERENCES
Allergan NA RELLE®
silicone gel- lled breast implant [package insert] data sheet.
Brinton LA, Buckley LM, Dvorkina O, et al. Risk o connective tissue disorders among breast implant patients. Am J Epidemiol.
2004;160;619–627.
Brinton LA, Lubin JH, Burich MC, Colton , Brown SL, Hoover RN. Breast cancer ollowing augmentation mammoplasty (United
States). Cancer Causes Control. 2000;11(9):819–827.
Brinton LA, Lubin JH, Burich MC, Colton , Brown SL, Hoover RN. Cancer risk at sites other than breast ollowing augmentation
mammoplasty. Ann Epidemiol. 2001;11(4):248–256.
Brinton LA, Lubin JH, Burich MC, Colton , Hoover RN. Mortality among augmentation mammoplasty patients. Epidemiology.
2001;12(3):321–326.
Brown SL, Pennello G, Berg WA, Soo MS, Middleton MS. Silicone gel breast implant rupture, extracapsular silicone, and health status
in a population o women. J Rheumatol. 2001;28(5):996–1003.
Committee on the Sa ety o Silicone Breast Implants, Institute o Medicine. In: Bondurant S, Ernster V, Herdman R, eds. Sa ety o
Silicone Breast Implants. Washington, DC: National Academies Press; 1999.
Hedén P, Nava MB, van etering JP, et al. Prevalence o rupture in inamed silicone breast implants. Plast Reconstr Surg. 2006;118:303–308.
Hölmich LR, Vejborg IM, Conrad C. Untreated silicone breast implant rupture. Plast Reconstr Surg. 2004;114:204–214.
Mentor MemoryGel silicone gel- lled breast implant product [package insert] data sheet.
National Cancer Institute Breast Implant Study: Fact Sheet; 2006.
Walker PS, Walls B, Murphy DK. Natrelle saline- lled breast implants: a prospective 10-year study. Aesthet Surg J. 2009;29:19–25.

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Karri A. Kluesner, MD and
Amanda L. Kong, MD, MS
BREAST CANCER RISK FACTORS/ SCREENING

What is the average woman’s li etime risk o developing breast cancer?
12.3%.

According to the 2014 National Comprehensive Cancer Network (NCCN) guidelines, what groups o
women have an increased risk o developing breast cancer?
1. History o breast cancer
2. 5-year risk o invasive breast cancer at least 1.7% in women 35 years old or older using the Gail model
3. Lobular carcinoma in situ (LCIS) or atypical ductal or lobular hyperplasia (ADH/ALH)
4. Li etime risk over 20% de ned by models based on amily history
5. History o thoracic radiation therapy when less than 30 years old
6. Family with suggested or known genetic predisposition

What is the modi ed Gail model?
A model that calculates 5-year and li etime projected probabilities o developing invasive breast cancer.

What criteria is the modi ed Gail model based on?
1. Age
2. Age at menarche
3. Age at rst live birth or nulliparity
4. Number o rst-degree relatives with breast cancer
5. Number o previous benign breast biopsies
6. Atypical hyperplasia in a previous breast biopsy
7. Race
Breast Cancer
CHAPTER 20

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When should a woman without a personal history o breast cancer be re erred or cancer genetic counseling
per 2015 NCCN guidelines?
I she has any o the ollowing:
1. A amily member with a known mutation in a breast cancer susceptibility gene or she is rom a population
with a known increased risk or genetic predisposition to developing breast cancer.
2. wo or more breast cancer primaries in a single individual or two or more breast cancer primaries diagnosed
rom the same side o the amily (maternal or paternal).
3. A amily member with a history o ovarian/ allopian tube/peritoneal cancer.
4. A rst- or second-degree relative with early-onset breast cancer, ≤45 years.
5. A amily member with a combination o breast cancer and one or more o the ollowing: pancreatic cancer, aggressive
prostate cancer, sarcoma, adrenocortical carcinoma, brain tumor, endometrial cancer, leukemia/lymphoma, thyroid
cancer, dermatologic mani estations, macrocephaly, hamartomatous GI polyps, or di use gastric cancer.
6. A amily history o male breast cancer.
7. A personal history o ovarian/ allopian tube/primary peritoneal cancer.

For women at normal risk between the ages o 25 and 39, how o ten should a clinical breast examination be
per ormed?
Every 1 to 3 years.

For women at normal risk aged 40 years and older, how o ten should a clinical breast examination be per ormed?
Annually.

What are the 2015 American Cancer Society Guidelines or screening mammography?
Optional annual mammograms or women ages 40 to 44, annual mammograms or women ages 45 to 54, and
annual or biennial mammograms or women 55 and older.

How o ten should women who have received prior thoracic irradiation be screened?
1. Age < 25, annual clinical breast examination starting 8 to 10 years a ter radiation.
2. Age ≥25, annual mammogram and MRI, and clinical breast examination every 6 to 12 months.
*Annual mammogram should occur 8 to 10 years a ter radiation exposure or at age 40, whichever occurs rst.

What are the NCCN screening guidelines or women 35 years or older with a 5-year risk o invasive breast
cancer ≥1.7%, based on the Gail model?
Annual mammogram and clinical breast examination every 6 to 12 months.

What are the NCCN screening guidelines or women with a li etime risk o breast cancer over 20%?
Clinical breast examination every 6 to 12 months and annual mammogram starting at age 30. In addition, annual
breast MRI is also recommended in women ≥30 years o age.

What are the NCCN screening guidelines or women with a history o LCIS or atypical hyperplasia?
Annual mammogram and clinical breast examination every 6 to 12 months.

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GENETICS

What is the risk o developing breast cancer by age 70 in women with a BRCA1 or BRCA2 mutation?
Approximately 65% risk in patients with BRCA1, 45% risk in patients with BRCA2 (U.S. Preventive Services
ask Force Recommendation Statement).

What cancers are associated with BRCA1 and BRCA2 mutations?
BRCA1 mutation is associated with increased risk o breast, ovarian, allopian tube, peritoneal, prostate, and
pancreatic cancer.
BRCA2 mutation is associated with increased risk o breast (especially in men), ovarian, prostate, and pancreatic cancer.
BREAST IMAGING

What is the overall sensitivity o screening mammography?
Approximately 75% (according to the NCCN guidelines 2015).

For screening mammography, what is the Breast Imaging Reporting and Data System (BI-RADS)
categorization?
Category 0: Incomplete assessment. Needs additional imaging evaluation and/or prior mammograms or comparison
Category 1: Negative
Category 2: Benign ndings
Category 3: Probably benign ndings
Category 4: Suspicious abnormality—biopsy should be considered
Category 5: Highly suggestive o malignancy—appropriate action should be taken
Category 6: Known biopsy-proven malignancy—appropriate action should be taken

For a Category 3 lesion, what is the likelihood o malignancy?
≤2%.

For a Category 5 lesion, what is the likelihood o malignancy?
≥95%.

Is MRI more sensitive than mammogram in the detection o breast cancer?
It is more sensitive, but less speci c.

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When is annual MRI recommended in breast cancer screening?
MRI is recommended in women with a BRCA mutation or a rst-degree relative o a BRCA carrier (untested), or
li etime risk o at least 20%. It is also recommended in women who received thoracic radiation between the ages
o 10 and 30, patients with Li-Fraumeni syndrome and their rst-degree relatives, and patients with Cowden and
Bannayan–Riley–Ruvalcaba syndromes and their rst-degree relatives.
MRI may be considered in patients with a 15% to 20% li etime risk o developing breast cancer, those with a
history o LCIS or ADH/ALH, those with dense or heterogeneous tissue on mammogram, and women with a
history o breast cancer.

What is the di erence between a screening mammogram and a diagnostic mammogram?
A diagnostic mammogram is per ormed when there are positive clinical ndings or an abnormality seen on
screening mammography. T e diagnostic mammogram includes spot compression and magni cation views.

Does breast ultrasound detect most microcalci cations?
No.
BENIGN BREAST LESIONS

What is brocystic disease?
A spectrum o clinical, mammographic, and histological ndings, present in 90% o women, representing an
abnormal tissue response to circulating hormones.

How does brocystic disease typically present?
Premenstrual cyclical mastalgia.

How does brocystic disease appear mammographically?
Bilateral symmetrical di use or ocally dense tissue.

Does presence o brocystic disease increase a woman’s risk o developing breast cancer?
No.

What is a galactocele, and how is it treated?
A milk- lled cyst that typically presents during or a ter cessation o breast- eeding. reatment involves aspiration
or operative excision.

What is the treatment o a palpable cyst?
Aspiration. I it recurs a ter several aspirations, surgical excision is warranted.

What is Mondor disease?
A benign disorder characterized by thrombophlebitis o the breast.

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What is a broadenoma?
A benign tumor consisting o stromal and epithelial elements. T ese tumors are estrogen sensitive.

What is the most common solid tumor ound in women younger than 30 years?
Fibroadenoma.

How do broadenomas present clinically?
A solid, rm, mobile mass.

What is the treatment o a typical broadenoma?
Excisional biopsy or observation.

What is a giant broadenoma?
A broadenoma that attains a size o greater than 5 cm in greatest dimension.

What is the typical history o a giant broadenoma?
A rapidly enlarging mass in the breast o a young adult or adolescent.

What is an intraductal papilloma?
A true polyp o epithelium-lined breast ducts.

What is the typical presentation o an intraductal papilloma?
Bloody nipple discharge.

What is the treatment or an intraductal papilloma?
Excisional biopsy. Excision is required because approximately 20% o core needle biopsy diagnosed intraductal
papillomas have been shown to be associated with malignancy.
PHYLLODES TUMOR

What is the typical history o a patient presenting with a phyllodes tumor?
Rapidly enlarging painless breast mass.

What is the mean age o presentation or a phyllodes tumor?
40 years, older than a patient with a broadenoma, but younger than a patient with invasive breast cancer.

Histologically, what is the makeup o a phyllodes tumor?
Composed o both stromal and epithelial elements.

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What are the subtypes o a phyllodes tumor?
1. Benign
2. Borderline
3. Malignant

What is the appropriate workup including type o biopsy or a patient with a suspected phyllodes tumor?
Patients should have a complete H&P, ultrasound, and mammogram (i over 30 years old). Excisional biopsy
should be per ormed. Fine needle aspiration does not distinguish a phyllodes tumor rom a broadenoma, and
core needle biopsy may not di erentiate them either. T ere ore, in patients with an indeterminate core needle
biopsy or one that is suggestive o broadenoma where there is a high clinical suspicion or a phyllodes tumor,
an excisional biopsy must be per ormed.

What is the appropriate treatment or a phyllodes tumor?
Local surgical excision with margins 1 cm or greater.

When is total mastectomy indicated?
When a negative margin cannot be obtained with lumpectomy or partial mastectomy.

Is axillary lymph node evaluation indicated in the treatment o phyllodes tumor?
No, phyllodes tumors rarely metastasize to the axillary lymph nodes. T ere ore, node dissection is not indicated.

In patients who experience a local recurrence o their phyllodes tumor, what is the recommended treatment?
Re-excision with tumor- ree margins o 1 cm. Radiation therapy is controversial in the treatment o phyllodes
tumors. In certain cases with more aggressive pathology, radiation therapy may be indicated.

Is systemic therapy using endocrine or cytotoxic agents indicated in the treatment o phyllodes tumors?
No.
BREAST CANCER STAGING

According to the 2010 American Joint Committee on Cancer breast cancer guidelines, how is breast cancer
staged?
According to NM staging.
umor:
x: tumor cannot be assessed
0: no tumor
is: in situ
1: < 20 mm
2: > 20 mm and < 50
3: > 50 mm
4: Extension into chest wall and/or skin

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Clinical nodes:
Nx: nodes cannot be assessed
N0: no lymph node metastasis
N1: metastasis to mobile ipsilateral level I and/or II axillary nodes
N2: metastasis to xed or matted ipsilateral level I and/or II axillary nodes or in clinically detected ipsilateral
internal mammary nodes in the absence o clinically evident axillary lymph node metastases
N3: metastasis to ipsilateral level III axillary nodes (with or without levels I/II axillary node involvement) or
clinically detected ipsilateral internal mammary nodes or ipsilateral supraclavicular nodal involvement
(with or without axillary or internal mammary lymph node involvement)
Pathologic nodes:
pNx: nodes cannot be assessed
pN0: no lymph node metastasis on histology
pN1: micrometastases or metastases in 1 to 3 axillary nodes or internal mammary nodes on histology, but not
clinically detected
pN2: metastases in 4 to 9 axillary nodes or clinically detected internal mammary nodes without axillary node
metastasis
pN3: metastases in > 10 axillary nodes, or level III axillary nodes, or ipsilateral supraclavicular nodes, or clinically
detected ipsilateral internal mammary nodes in certain settings
Metastasis:
M0: no distant metastasis
M1: distant metastasis
Staging:
Stage 0: is N0 M0
Stage IA: 1 N0 M0
Stage IB: 0 or 1 N1mi M0
Stage IIA: 0 or 1 N1 M0 or 2 N0 M0
Stage IIB: 2 N1 M0 or 3 N0 M0
Stage IIIA: 0, 1, or 2 N2 M0 or 3 N1 or N2 M0
Stage IIIB: 4 any N M0
Stage IIIC: Any N3 M0
Stage IV Any Any N M1
Adapted rom the American Joint Committee on Cancer Staging Manual, Seventh Edition, 2010.

What is the most important prognostic actor ollowing a diagnosis o breast cancer?
Node status.

In women receiving appropriate therapy, what is the 5-year relative survival or Stage I disease, Stage II
disease, Stage III disease, and Stage IV disease?
Stage I: 98%
Stage II: 86%
Stage III: 57%
Stage IV: 20%

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LOBULAR CARCINOMA IN SITU (LCIS)

Following the recommended workup including history and physical examination (H&P), diagnostic
bilateral mammography, and biopsy with pathology review, what is the treatment or LCIS?
I LCIS is ound on a core biopsy, surgical excision should be per ormed to rule out invasive cancer. Once the lesion
has been excised and LCIS is con rmed, treatment consists o counseling regarding risk reduction and surveillance.

What is the risk o developing an invasive breast cancer once diagnosed with LCIS?
Approximately 10% to 20% risk or subsequent development o cancer in either breast over the next 15 years.

rue or False. T e risk o invasive breast cancer a ter the diagnosis o LCIS is equal in both breasts.
rue.

In a woman diagnosed with LCIS who wishes to undergo risk reduction surgery, what is the appropriate
management?
Bilateral mastectomies.

Do women with a diagnosis o LCIS bene t rom tamoxi en therapy?
Yes, 46% relative risk reduction in the NSABP-1 trial (hazard ratio 0.54).
DUCTAL CARCINOMA IN SITU (DCIS)

Following the recommended workup including H&P, diagnostic bilateral mammography, core needle biopsy
and pathology review, what urther test is required in the workup o DCIS?
Hormone receptor determination.

What are the two primary locoregional treatment options or women with DCIS?
1. Lumpectomy plus radiation.
2. otal mastectomy and sentinel lymph node biopsy + /– reconstruction.

When is determination o lymph node status indicated in DCIS?
When the patient chooses to have a mastectomy, in the event occult invasive disease is detected on nal pathology
or i invasive disease is ound incidentally in the specimen a ter a lumpectomy is per ormed or pure DCIS. Nodal
evaluation is not indicated in pure DCIS.

In margin-negative excision o DCIS, does whole breast radiation decrease the rate o in-breast disease
recurrence?
Yes, by about 50% to 60%.

In margin-negative excision o DCIS, does whole breast radiation improve overall survival or metastasis- ree
survival?
No.

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Following breast-conserving therapy, is there a bene t o hormonal therapy in the treatment o DCIS?
Yes, in hormone-receptor-positive disease, tamoxi en has been shown to decrease the risk o recurrence in the
ipsilateral breast and the risk o developing cancer in the contralateral breast.

What is included in ollow-up or DCIS treatment?
H&P every 6 to 12 months, along with annual mammography o both the a ected breast i breast conserving
surgery is per ormed as well as the contralateral breast. I a mastectomy is per ormed, then only screening
mammography o the contralateral breast. In women receiving breast-conserving therapy, the rst ollow-up
mammogram should be per ormed 6 to 12 months a ter the completion o radiation therapy.

With a recurrence o DCIS, what is the recommended treatment in women who previously received
breast-conserving therapy?
Mastectomy. Breast conservation therapy should not be repeated because o a history o prior radiation.
INVASIVE BREAST CANCER

What percentage o invasive carcinomas are ductal in origin?
85% to 90% ductal and approximately 10% lobular.

What is the recommended NCCN workup ollowing the diagnosis o invasive breast cancer?
H&P, complete blood cell count, platelet count, liver unction tests, bilateral diagnostic mammography, breast
ultrasound (i necessary), possible MRI, tumor ER and PR determinations, human epidermal growth actor
receptor-2 (HER2) tumor status determination, pathology review, genetic counseling in appropriate patients, and
consider ertility counseling in appropriate patients.

When should breast MRI be considered or staging purposes (not screening)?
o de ne the extent o cancer or the presence o multi ocal cancer to evaluate or breast conservation, or or
evaluation be ore and a ter neoadjuvant therapy to evaluate response to treatment.

What additional staging workup is indicated in patients with nodal disease?
Chest C , abdominal (and pelvic) C or MRI, bone scan, or PE scan may be considered.

What is the most common site o disseminated disease?
Bone.

What are the locoregional treatment options or Stage I and Stage II invasive breast cancers?
Mastectomy with or without reconstruction, with a sentinel lymph node biopsy (SLNB) and axillary dissection i
SLNB is positive.
Breast-conserving therapy (lumpectomy, SLNB, radiation, and axillary dissection i SLNB is positive). In certain
circumstances urther axillary surgery can be omitted in the setting o a positive SLNB.

Is there a survival bene t in patients undergoing mastectomy rather than lumpectomy with whole breast
irradiation?
No.

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What are the oncologic landmarks in a simple mastectomy?
Clavicle, sternum, in ramammary old, and latissimus dorsi. T e pectoralis ascia is removed.

What is a radical mastectomy, a modi ed radical mastectomy, simple mastectomy, and a lumpectomy?
1. Radical mastectomy:
• Rarely per ormed, includes removal o all breast tissue, pectoralis ascia, pectoralis musculature (major and
minor), and regional lymph nodes
2. Modi ed radical mastectomy:
• Removal o all breast tissue, including the nipple–areolar complex, along with the removal o level I and II
axillary lymph nodes
3. Simple mastectomy:
• Removal o all breast tissue, including the nipple–areolar complex
4. Lumpectomy:
• Excision o the primary tumor with preservation o the breast

What are absolute contraindications or breast-conserving therapy in invasive breast cancer?
1. Previous moderate-to-high dose radiation to the breast or chest wall.
2. Pregnancy i the patient will require radiation therapy during the time o pregnancy.
3. Di use suspicious or malignant-appearing microcalci cations on mammography.
4. Widespread disease.

What are relative contraindications or breast-conserving therapy?
1. Active connective tissue disease involving the skin (i.e., scleroderma, lupus).
2. umors greater than 5 cm.
3. A ocally positive margin.
4. History o radiation to the chest wall or breast.
5. Known or likely genetic predisposition to breast cancer.

What are contraindications or nipple–areolar complex sparing mastectomy?
1. umor < 2 cm away rom nipple
2. Evidence o nipple involvement (Paget’s, bloody discharge, retraction)
3. Positive lymph nodes
4. In ammatory breast cancer
5. Skin involved with tumor
From a reconstruction perspective, women who are smokers, diabetic, have Regnault grade 3 ptosis or modi ed
Regnault grade 4 ptosis (nipples pointing toward the oor), are obese or have oversized breasts are not good
candidates or nipple-sparing mastectomies.
A retroareolar resection should be per ormed and negative margins con rmed when per orming a nipple-sparing
mastectomy.

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Following total mastectomy, what are indications or chest wall and regional radiation therapy?
1. Presence o our or more positive axillary lymph nodes.
2. I 1 to 3 positive axillary nodes, it should be strongly considered.
3. I the tumor is > 5 cm, it should be considered, regardless o node status.

What is the positive predictive value o success ul sentinel lymph node biopsy?
100%.

What is the negative predictive value o success ul sentinel lymph node biopsy?
95%.

I a sentinel node biopsy is positive, ormal axillary dissection should involve what lymph node levels?
Levels 1 and 2 (see Fig. 20-1).
Figure 20-1 Lymph node levels o axillary dissection.

A minimum o how many lymph nodes should be provided to accurately stage the axilla?
10.

I adjuvant chemotherapy is indicated, when should radiation begin?
Upon completion o chemotherapy.

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Is there a di erence in survival or local/regional recurrence between patients undergoing a total mastectomy
without reconstruction versus skin-sparing mastectomy?
No.

When should preoperative chemotherapy be considered and what is its rationale?
Stage IIA, Stage IIB, 3N1M0 tumors in women who meet all criteria or breast conservation therapy with the
exception o tumor size. Rationale: allows or downstaging o primary tumor, making breast conserving surgery
possible in cases where mastectomy would otherwise be required.
HER2-positive tumors should be treated with preoperative trastuzumab + /– pertuzamab.

In women with positive axillary lymph nodes, does chest wall and regional lymph node radiation improve
disease- ree and overall survival?
Yes. T e MA.20 trial ound improved disease ree survival and a trend toward improved overall survival when the
supraclavicular, in raclavicular, ipsilateral internal mammary chain, and level 3 axillary nodes were radiated in
addition to the breast in patients with 1 to 3 positive lymph nodes.

What is HER2 and why is it important?
HER2, or HER2/neu is a member o the epidermal growth actor receptor amily. HER2 is an acronym
or human epidermal growth actor receptor 2. It is help ul or prognostic purposes and provides predictive
in ormation used in selecting optimal adjuvant/neoadjuvant therapy. umors with ampli cation o the HER2 gene
have an increased risk o recurrence and generally carry a worse prognosis.

What is DNA microarray (i.e., MammaPrint and Oncotype DX®
) technology and what is its importance?
1. Assay that determines the gene expression pro le in breast tumor tissue.
2. Provides prognostic in ormation and risk o distant metastases, particularly in node-negative disease.
3. Can help to identi y patients who will bene t rom hormonal therapy and/or chemotherapy in combination
with hormonal therapy.

Who should be re erred or onco ertility counseling?
Any premenopausal patient who will be undergoing chemotherapy. Patients should be counseled not to become
pregnant during radiation therapy, chemotherapy, or hormonal therapy. Hormone-based contraceptives should be
discontinued.
ADJUVANT TREATMENT (HORMONAL)

What is the goal o hormonal therapy?
o prevent tumor cell stimulation rom estrogen.

What methods o hormonal manipulation are available?
1. Estrogen receptor blockers (tamoxi en)
2. Blockers o estrogen synthesis (aromatase inhibitors)
3. Ovarian ablation (surgical or medical)

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How does tamoxi en work?
amoxi en is a selective estrogen receptor modulator. amoxi en acts as a competitive estrogen antagonist in breast
tissue but not in other estrogen-sensitive tissues.

What patients are not candidates or hormonal therapy?
Patients with hormone-receptor-negative breast cancer.

In premenopausal women with node-positive and hormone-receptor-positive disease, what adjuvant
treatment is indicated?
Chemotherapy and hormonal therapy (tamoxi en should be delayed until completion o chemotherapy).

Should patients with invasive breast cancer that are ER- or PR-positive always receive anti-endocrine therapy
regardless o age, lymph node status, or adjuvant chemotherapy?
Yes.

In women with ER-positive breast cancer, how greatly does adjuvant tamoxi en therapy decrease annual
odds o recurrence and annual odds o death?
Decreases annual breast cancer recurrence rate (relative risk [RR]) by 39%.
Decreases annual breast cancer death rate (RR) by 31%.

What is the optimal duration o adjuvant tamoxi en therapy?
5 to 10 years. T e A LAS trial ound improved recurrence rates (new or same tumor, local, regional, or distant,
including the contralateral side), disease-speci c survival and overall mortality rates when tamoxi en was taken or 10
years rather than 5 by patients with ER-positive tumors. T e NCCN guidelines recommend 5 to 10 years o treatment.

In postmenopausal women with early-stage breast cancer, is there a bene t o adding an aromatase inhibitor
or adjuvant treatment?
Yes, multiple studies have shown a survival bene t when adding aromatase inhibitors (AIs) to the adjuvant
regimen in postmenopausal women. T e A AC trial showed AIs alone to be superior to treatment with tamoxi en
or tamoxi en combined with an AI in postmenopausal women. Currently, rst-line adjuvant hormonal therapy in
postmenopausal women consists o AIs.

Which class o endocrine therapy drugs is associated with osteoporosis?
Aromatase inhibitors.

Which endocrine therapy drug is associated with increased risk o endometrial cancer and DV ?
amoxi en.

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ADJUVANT TREATMENT (CHEMOTHERAPY)

When is systemic adjuvant chemotherapy indicated?
umor > 1 cm or positive lymph nodes.
Oncotype DX is a genomic assay used in ER-positive, node-negative patients. It estimates distant recurrence risk
within 10 years. Patients with a high calculated risk have improved recurrence ree survival and disease-speci c
survival when they are treated with adjuvant chemotherapy.
Patients with HER2-positive tumors should be treated with trastuzumab (Herceptin) in addition to chemotherapy.

What is Herceptin?
Herceptin (trastuzumab) is a monoclonal antibody that targets the extracellular domain o HER2. Five trials using
adjuvant Herceptin have shown improved disease- ree survival in patients with HER2-positive breast cancer.

What are some techniques or preservation o ertility?
Chemotherapy can cause in ertility and early menopause. Fertility can be preserved by cryopreservation o oocytes
and embryos, ovarian tissue cryopreservation, or ovarian suppression with gonadotropin-releasing hormone
analogs.
MALE BREAST CANCER

What percentage o all breast cancers does male breast cancer account or?
0.8%

What percentage o male cancers does male breast cancer account or?
< 1%.

What acquired risk actors are associated with male breast cancer?
Age, hormonal imbalance (secondary to testicular disease), in ertility, obesity, liver disease, and radiation exposure.

What genetic risk actors predispose to male breast cancer?
Kline elter syndrome, amily history, Jewish ancestry, and BRCA-2 mutation.

What is the li etime risk o a male with a BRCA-2 mutation developing breast cancer?
Approximately 5% to 10%.

Is gynecomastia a risk actor or the development o male breast cancer?
No.

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ANGIOSARCOMA

What is angiosarcoma?
A highly aggressive sarcoma originating rom lymphatic or capillary endothelium. Angiosarcoma o the breast or
upper extremity can occur as a primary tumor, or more commonly as a secondary tumor ollowing treatment or
breast cancer.

What is the time interval between breast cancer diagnosis and development o subsequent upper extremity
or chest angiosarcoma?
5 to 10 years.

What syndrome describes upper extremity sarcoma development associated with lymphedema ollowing
radical mastectomy?
Stewart– reves syndrome.

What is a risk actor or the development o angiosarcoma ollowing breast cancer treatment?
Upper extremity lymphedema.

Where does angiosarcoma most commonly spread?
Hematogenous spread to the lungs and bones.

What is the prognosis o angiosarcoma dependent on?
Histologic grade and tumor size.
PAGET’S DISEASE OF THE BREAST

What is Paget’s disease o the breast?
A rare mani estation o breast cancer characterized by neoplastic cells in the epidermis o the nipple–areolar complex.

How o ten is Paget’s disease associated with cancer elsewhere in the breast?
80% to 90%. T e cancer may be invasive or DCIS.

What is the appropriate workup or a woman presenting with bleeding, ulceration, and/or pruritus o the
nipple?
1. H&P.
2. Diagnostic mammography.
3. Biopsy o any breast lesion.
4. Full-thickness skin biopsy o clinically involved nipple–areolar complex.
5. Consider breast MRI to identi y extent o disease i skin biopsy is positive or Paget’s disease.