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388 Part VIII&Breast Surgery
VASCULAR SUPPLY
6. During a mastectomy, which of the following vessels is the most critical to preserve perfusion to the skin and
nipple-areola complex?
A. 2nd internal mammary artery perforator.
B. Lateral thoracic artery.
C. Thoracoacromial artery.
D. Intercostal perforators.
E. Thoracodorsal artery.
INNERVATION
7. Which of the following nerves primarily supplies sensation to the nipple-areolar complex?
A. Intercostobrachial nerve.
B. T3 branch of intercostal nerve.
C. T4 branch of intercostal nerve.
D. T5 branch of intercostal nerve.
E. T6 branch of intercostal nerve.
SKIN AND PARENCHYMA
8. A 63-year-old female presents for consultation for mastopexy. On examination, she has deflated breasts, with
grade III ptosis of the nipple bilaterally. Attenuation of which of the following structures is responsible for
this presentation?
A. Ductal tissue.
B. Glandular tissue.
C. Fatty tissue.
D. Cooper's ligaments.
E. Dermis.
UNDERLYING MUSCULATURE
9. Which of the following muscles is used as a landmark to identify different nodal zones during an axillary
dissection?
A. Pectoralis major.
B. Pectoralis minor.
C. Serratus anterior.
D. Intercostal.
E. Latissimus dorsi.
BREAST EXAMINATION
10. A 43-year-old female presents for consultation for reduction mammoplasty. At which time is it most comfort-
able for the patient to perform a full breast examination?
A. Premenstrual.
B. Follicular phase.
C. Luteal phase.
D. Menstruation.
E. Postmenstrual phase.
Chapter 51&Breast Anatomy 389
Answers
EMBRYOLOGY, DEVELOPMENT, AND PHYSIOLOGY
1. The mammary gland is derived from which of the following cell lines?
C. Ectoderm.
The mammary glands form from ingrowths of ectoderm that become lactiferous glands and ducts. Around
weeks 6 to 7 of gestation, the milk ridge develops beginning with 15 to 20 buds that then undergo apoptosis
to leave a single pair of buds at the fourth or fifth intercostal space. The nipple develops with surrounding
circular smooth muscle fibers derived from mesoderm.
REFERENCE
1. Lemaine V, Simmons PS. The adolescent female: breast and reproductive embryology and anatomy. Clin Anat
2013;26(1):22–28
EMBRYOLOGY, DEVELOPMENT, AND PHYSIOLOGY
2. A 19-year-old female presents with complete absence of the right breast and nipple. She has no abnormalities
of her extremities or pectoralis muscle. Her chest wall is in good position and size. Which of the following
terms best describes the anatomic variation?
A. Amastia.
There are several congenital breast anomalies that the plastic surgeon should be familiar with. Amastia is the
congenital absence of both the breast and the nipple. Patients with amazia haveabsenceof the breast but presence of a nipple, and those with athelia have presence of a breast, but absence of the nipple. Patients with
Poland syndrome will have an absent or hypoplasticbreast, as well as other anomalies of other chest wall components including the latissimus dorsi, ribs, and serratus muscle, among others. The most common limb
abnormality is brachysyndactyly on the affected side. Treatment is typically with a tissue expander initially,
followed by a submuscular implant and latissimus dorsi flap after the contralateral breast stops growing.
Anterior thoracic hypoplasia presents with unilateral sunken anterior chest wall, hypoplasia of the breast,
superiorly placed nipple-areola complex, normal pectoralis muscle, and normalsternalposition.
1
1
1
REFERENCE
1. Hatono A, Nagasao T, Sotome K, et al. A case of congenital unilateral amastia. J Plast Reconstr Aesthet Surg
2012;65(5):671–674
EMBRYOLOGY, DEVELOPMENT, AND PHYSIOLOGY
3. A 20-year-old female presents with complaints of polymastia. Which is the most likely area of accessory breast
tissue found on examination?
C. Lower lateral chest wall.
Accessory breast t issue (supernumerary breast, polymastia) is common. Polymastia most commonly
presents along the mammary line, with the most common location along the lateral inframammary fold.
Another common location is the groin. Patients will present with cyclical pain as this breast tissue is
responsive to hormonal influence. Treatment is surgical excision.
1,2
REFERENCES
1. Bourguignon JP, Juul A. Normal female puberty in a developmental perspective. Endocr Dev 2012;22:11–23
2. Gusterson BA, Stein T. Human breast development. Semin Cell Dev Biol 2012;23(5):567–573
390 Part VIII&Breast Surgery
EMBRYOLOGY, DEVELOPMENT, AND PHYSIOLOGY
4. A young female patient is brought in by her parents regarding concerns of breast asymmetry. She has absence
of any breast tissue but presence of the nipple of one side of her chest. On the contralateral chest, she has
presence of glandular tissue and areolar pigmentation with a secondary mound formed by the nipple above
the level of the breast. What stage of breast development is this patient by the Tanner classification?
D. 4.
The Tanner scale (Tanner stages) is a scale of physical development in children based on external
primary and secondary sex characteristics. The patient in this question has development of subareolar
breast tissue with a second mound formed by the nipple and areola above the level of the breast which
occurs in Tanner stage 4 breasts. In Tanner stage 5 breasts, the areola returns to the contour of the
surrounding breast with a central projecting papilla. Tanner stage 3 breasts have elevation of the breast
mound; however, the areola remains in contour with the surrounding breast.
1
REFERENCE
1. Tanner JM, ed. Growth at Adolescence. 2nd ed. Oxford: Blackwell Scientific; 1978
EMBRYOLOGY, DEVELOPMENT, AND PHYSIOLOGY
5. A 5-year-old girl's parents are concerned as their daughter has started to develop breasts. Upon examination,
the patient has bilateral stage 4 Tanner breast development but no other signs of puberty or skeletal maturation. This patient's condition is best represented by which of the following?
A. Premature thelarche.
Premature thelarche occurs when breast development starts before the age of 8 years without evidence of
other signs of puberty including pubic hair or vaginal mucosal thickening. Symptoms are typically bilateral
and end after 3 to 5 years. In Poland syndrome there will be an absent or hypoplastic breast, as well as
other anomalies of other chest wall components including the latissimus dorsi, ribs, and serratus muscle,
among others. Jeune syndrome presents with a narrow, immobile breast and renal disease. Supernumerary
breast is accessory mammary tissue forming along the embryonic milk line (axilla to groin).
1
REFERENCE
1. Bostwick J III. Anatomy and physiology. In: Bostwick J III, ed. Plastic and Reconstructive Breast Surgery. 2nd ed.
New York: Thieme Publishers; 2000
VASCULAR SUPPLY
6. During a mastectomy, which of the following vessels is the most critical to preserve perfusion to the skin and
nipple-areola complex?
A. 2nd internal mammary artery perforator.
The soft tissue of the breast has a rich vascular supply through a diffuse subdermal plexus that
communicates with underlying deeper vessels supplying the breast parenchyma. These vessels include
perforators from the lateral thoracic artery, thoracoacromial, intercostal, internal mammary, and
thoracodorsal vessels. The 2nd and 3rd interspace perforators of the internal mammary are typically the
dominant blood supply to the breast skin and nipple-areola complex and should be preserved during
mastectomy and reconstruction to minimize the risk of ischemic complications of the skin envelope.
1,2
REFERENCES
1. Bostwick J III. Anatomy and physiology. In: Bostwick J III, ed. Plastic and Reconstructive Breast Surgery. 2nd ed.
New York: Thieme Publishers; 2000
2. Shermak MA. Female breast anatomy. In: Shermak MA, ed. Body Contouring. New York: McGraw-Hill
Professional; 2011:60–61
INNERVATION
7. Which of the following nerves primarily supplies sensation to the nipple-areolar complex?
C. T4 branch of intercostal nerve.
The breast has a dermatomal innervation supplied by the anterior and lateral cutaneous branches of the T2–T6
(primarily T3–T5) intercostal nerves. The supraclavicular nerves of the cervical plexus also provide innervation
Chapter 51&Breast Anatomy 391
to the upper and lateral portions of the breast. The nipple-areolar complex is primarily supplied by the T4
branch. The lateral branch usually runs deep along the pectoral fascia while the anterior cutaneous branch
runs superficially, and therefore is the only preserved branch after a mastectomy is performed.
1
REFERENCE
1. Schlenz I, Kuzbari R, Gruber H, et al. The sensitivity of the nipple-areola complex: an anatomic study. Plast
Reconstr Surg 2000;105:905
SKIN AND PARENCHYMA
8. A 63-year-old female presents for consultation for mastopexy. On examination, she has deflated breasts, with
grade III ptosis of the nipple bilaterally. Attenuation of which of the following structures is responsible for
this presentation?
D. Cooper's ligaments.
The breast parenchyma extends from the second to seventh ribs and from the sternocostal junction to
midaxillary line with an additional extension into the axilla. The breast parenchyma is enveloped by a
superficial layer of superficial fascia as well as a deep layer of the superficial fascia. The inframammary fold at
the lower border of the breast is the fusion of the deep and superficial fascia with the dermis and is a zone of
adherence. Cooper's ligaments are fibrocollagenous septa that penetrate the deep layer of the superficial fascia
through breast parenchyma to the dermis. It is the attenuation of these ligaments that results in breast ptosis.
1,2
REFERENCES
1. Jones G, ed. Bostwick's Plastic and Reconstructive Breast Surgery. 3rd ed. New York: Thieme Publishers; 2010
2. Hall-Findlay EJ, ed. Aesthetic Breast Surgery: Concepts & Techniques. New York: Thieme Publishers; 2011
UNDERLYING MUSCULATURE
9. Which of the following muscles is used as a landmark to identify different nodal zones during an axillary dissection?
B. Pectoralis minor.
The pectoralis minor muscle originates on the surfaces of the third through sixth ribs and inserts onto
the coracoid process of the scapula to draw the scapula inferiorly and anteriorly. This muscle serves as a
landmark during axillary dissection as its lateral margin divides the superficial from the deep axillary
nodes. The majority of lymph nodes from the breast drain into the axillary lymph node basin and are
classified as Level I, lateral to the lateral border of the pectoralis minor; level II, behind the pectoralis
minor and below the axillary vein; and level III, medial to the medial border of the pectoralis minor.
1,2
REFERENCES
1. Jones G, ed. Bostwick's Plastic and Reconstructive Breast Surgery. 3rd ed. New York: Thieme Publishers; 2010
2. Hall-Findlay EJ, ed. Aesthetic Breast Surgery: Concepts & Techniques. New York: Thieme Publishers; 2011
BREAST EXAMINATION
10. A 43-year-old female presents for consultation for reduction mammoplasty. At which time is it most comfort-
able for the patient to perform a full breast examination?
E. Postmenstrual phase.
The breast examination and patient's breast symptoms change with the menstrual cycle. The follicular phase
(days 4–14) involves mitosis and proliferation of breast epithelial cells. In the luteal phase (days 5–28), the
mammary ducts dilate and estrogen increases blood flow to the breast. The breast involutes with decrease in
circulating hormones during menstruation. Breast engorgement and sensitivity peaks during the
premenstrual phase and hits a nadir around 5 to 7 days after menstruation at which point palpation is most
sensitive for detecting masses and the breast examination is most comfortable for the patient.
1,2
REFERENCES
1. Bostwick J III. Anatomy and physiology. In: Bostwick J III, ed. Plastic and Reconstructive Breast Surgery. 2nd ed.
New York: Thieme Publishers; 2000
2. August DA, Sondak VK. Breast. In: Greenfield LJ, Mulholland M, Oldham KT, et al, eds. Surgery: Scientific
Principles and Practice. 2nd ed. Philadelphia: Lippincott-Raven; 1997
52. Breast Augmentation
Nima Khosravani, Anup Patel, Anmol Chattha
See Essentials of Aesthetic Surgery, pp. 723–750
SILICONE IMPLANTS
1. Which of the following is true of silicone implants?
A. Saline implants lost popularity during the 1990s as a result of the silicone scare.
B. In 1999, the NIH Institute of Medicine and the National Academy of Sciences reviewed 17 epidemiologic
studies and were unable to link silicone implants with autoimmune, systemic, and prenatal disease.
C. Fifth-generation silicone implants consist of a thick (0.25 mm) shell, with thick viscous gel, and a Dacron
patch.
D. First-generation silicone implants consist of a cohesive silicone gel–filled device with inner laminar layer to
prevent gel bleeds.
E. Saline implants were introduced first before silicone implants.
PREOPERATIVE PLANNING
2. A 19-year-old female comes in desiring breast augmentation. She would like silicone implants. She has a past
medical history of anxiety, Poland syndrome, and depression. She notes she does not have any social pressure
to get a breast augmentation; however, all of her friends in college have saline implants. Which of the following is a contraindication for silicone breast augmentation?
A. Her past medical history of anxiety and depression.
B. Patient's age.
C. Her relationship status.
D. Poland syndrome.
E. The fact that all her friends have saline implants.
PREOPERATIVE PLANNING
3. Which of the following is not important during the preoperative evaluation of the patient?
A. Motivation for surgery.
B. Psychological state of mind and stability.
C. Expectations.
D. Household income.
E. Self-esteem.
PREOPERATIVE PLANNING
4. What is an advantage to using silicone implants versus saline implants?
A. Adjusts quickly to body core temperature.
B. Leaks are easily detected and safely absorbed by the body.
C. Sizes are more customizable, and easier to adjust for size and correct breast asymmetries.
D. More natural feel and appearance.
E. Ability to fill implants in clinic postoperatively.
PREOPERATIVE PLANNING
5. Which of the following is an advantage to using saline versus silicone implants?
A. More natural feel and appearance.
B. Historically lower contracture rates.
C. Complete deflation with leak.
D. Wrinkling.
E. Increased viscosity.
Chapter 52&Breast Augmentation 393
PREOPERATIVE PLANNING
6. What volume increases volume by one cup size in an average body frame?
A. 50–75 cc.
B. 125–150 cc.
C. 200–225 cc.
D. 250–275 cc.
E. 300–325 cc.
PREOPERATIVE PLANNING
7. What is an advantage to using textured implants over smooth implants?
A. Thinner capsule is formed.
B. Less palpable.
C. Lower contracture rate.
D. Easy postoperative manipulation to achieve desired positioning.
E. Lower risk of BIA-ALCL.
PREOPERATIVE PLANNING
8. Which type of implant has the lowest rate of contracture?
A. Smooth.
B. Textured.
C. Polyurethane-covered.
D. Silicone.
E. Round.
PREOPERATIVE PLANNING
9. A 34-year-old female wants to undergo a large breast augmentation with 450 cc bilateral implants. Which of
the following is true of implants >400 cc?
A. They are considered medium–volume implants and are less prone to complications.
B. They are considered medium–volume implants and are more prone to complications.
C. They are considered high–volume implants and are less prone to complications.
D. They are considered high–volume implants and are more prone to complications.
E. They are considered ultra-high-volume implants; however, do not have any increased complication rates.
PREOPERATIVE PLANNING
10. Which of the following is an advantage of a subglandular/subfascial implant?
A. Has the lowest capsular contracture rate.
B. Avoids implant distortion with pectoralis activity (in a muscular patient).
C. Prevents double-bubble formation.
D. Does not interfere with mammography.
E. Has a lower infection rate.
PREOPERATIVE PLANNING/ANATOMIC PRINCIPLES
11. What is a disadvantage to performing dual plane II and dual plane III?
A. Usually restricted to IMF incisions.
B. Usually restricted to periareolar incision.
C. Usually restricted to axillary incision.
D. Does not allow for complete visualization of subglandular or submuscular pocket.
E. Decreased lower pole arc stretch.
ANATOMIC PRINCIPLES/OPERATIVE TECHNIQUE
12. Which of the following differentiates dual plane type I, II, and III?
A. Thickness of the pectoralis muscle.
B. Proximity of the dissection to the areolar tissue.
C. The extent and level of separation of pectoralis from parenchyma.
D. Position of the incision.
E. Subcutaneous undermining level.
394 Part VIII&Breast Surgery
ANATOMIC PRINCIPLES/OPERATIVE TECHNIQUE
13. Which type of dissection involves separation of pectoralis from breast parenchyma in the retromammary
plane to the level of the inferior NAC?
A. Dual plane I.
B. Dual plane II.
C. Dual plane III.
D. Subglandular.
E. Total submuscular.
OPERATIVE TECHNIQUE
14. A surgeon is looking to minimize contamination of a breast implant he or she is inserting. Which maneuver
is the best one to prevent implant contamination?
A. Postoperative antibiotics.
B. No touch technique.
C. Rinsing the implant in saline before insertion.
D. Using drains.
E. Using sizers.
PREOPERATIVE PLANNING/POSTOPERATIVE CARE
15. What percentage of patients will experience permanent sensory changes following breast augmentation?
A. 3%.
B. 7%.
C. 15%.
D. 22%.
E. 30%.
POSTOPERATIVE CONSIDERATIONS
16. Which of the following is true of postoperative rippling?
A. It is most commonly due to overfilling.
B. It is most commonly found in the upper pole of underfilled implants.
C. It is most commonly seen in silicone implants.
D. Traction rippling is seen in smooth implants.
E. It is primarily due to preoperative patient risk factors.
POSTOPERATIVE CARE
17. What is the leak/rupture rate associated with saline implants at 10 years?
A. 2–5%.
B. 5–10%.
C. 10–15%.
D. 15–20%.
E. 20–25%.
CAPSULAR CONTRACTURE/POSTOPERATIVE CARE
18. Which of the following Baker classifications is characterized by severe contracture and pain?
A. Grade I.
B. Grade II.
C. Grade III.
D. Grade IV.
E. Grade V.
CAPSULAR CONTRACTURE/POSTOPERATIVE CARE
19. Which of the following is historically true of capsular contractures?
A. The majority will occur within 3 to 4 months.
B. Subglandular implants have a significantly lower contracture rate at 10 years when compared to sub-
pectoral implants.
C. Textured implants have a significantlylowercontracture rate at 10 years when compared to smooth implants.
Chapter 52&Breast Augmentation 395
D. Silicone implants have a significantly lower contracture rate at 10 years when compared to saline implants.
E. Closed capsulotomy is the treatment of choice.
BIA-ALCL: POSTOPERATIVE CARE
20. Which of the following is true of breast implant associated anaplastic large cell lymphoma (BIA-ALCL)?
A. It is a cancer of the breast tissue.
B. It is associated with only silicone implants.
C. It is associated with only saline implants.
D. It is associated with CD30 positive and ALK-negative T-cell lymphocytes.
E. It is associated only with smooth implants.
396 Part VIII&Breast Surgery
Answers
SILICONE IMPLANTS
1. Which of the following is true of silicone implants?
B. In 1999, the NIH Institute of Medicine and the National Academy of Sciences reviewed 17 epidemiologic
studies and were unable to link silicone implants with autoimmune, systemic, and prenatal disease.
In 1999, the NIH Institute of Medicine and the National Academy of Sciences reviewed 17 epidemiologic
studies and were unable to detect any link between silicone implants and autoimmune, systemic, and
prenatal disease. Saline implants increased in popularity during the 1990s because of the silicone scare. Firstgeneration silicone implants consist of a thick (0.25 mm) shell, thick viscous gel, and Dacron patch whereas
fifth-generation silicone implants consist of a cohesive silicone gel–filled device with inner laminar layer to
prevent gel bleed.
REFERENCES
1. American Society of Plastic Surgeons. Procedural statistics trends 1992–2004. Available at www.plasticsurgery.
org/public_education/Statistical-Trends.cfm
2. Silicone gel-filled breast implants approved. FDA Consum 2007;41:8
PREOPERATIVE PLANNING
2. A 19-year-old female comes in desiring breast augmentation. She would like silicone implants. She has a past
medical history of anxiety, Poland syndrome, and depression. She notes she does not have any social pressure
to get a breast augmentation; however, all of her friends in college have saline implants. Which of the following is a contraindication for silicone breast augmentation?
B. Patient's age.
Silicone implants are not FDA approved for women <22 years of age. Poland syndrome would be a good
indication for breast augmentation. The desire to improve body image, symmetry and balance, rejuvenation
after postpartum deflation, and the desire to correct breast asymmetry are all indications for breast
augmentation. Social instability (e.g., divorce or separation, searching for a relationship) is a contraindication.
1,2
1,2
REFERENCES
1. Rohrich R. Streamlining cosmetic surgery patient selection—just say No! Plast Reconstr Surg 1999;104:220
2. Gorney M. Patient selection criteria. Medicolegal issues in plastic surgery. Clin Plast Surg 1999;26:37
PREOPERATIVE PLANNING
3. Which of the following is not important during the preoperative evaluation of the patient?
D. Household income.
During the preoperative evaluation, the following should be assessed: motivation for surgery, psychological
state of mind and stability, level of understanding, expectations, and self-esteem. Household income is not
typically assessed directly by the surgeon preoperatively, although financial details of surgery would be discussed with the patient through the surgeon's office staff.
1,2
REFERENCES
1. Rohrich R. Streamlining cosmetic surgery patient selection—just say No! Plast Reconstr Surg 1999;104:220
2. Gorney M. Patient selection criteria. Medicolegal issues in plastic surgery. Clin Plast Surg 1999;26:37
PREOPERATIVE PLANNING
4. What is an advantage to using silicone implants versus saline implants?
D. More natural feel and appearance.
Silicone implants have a more natural feel and appearance than saline implants; however, saline
implants adjust quickly to body core temperature, leaks are easily detected and safely absorbed, and are
more customizable. Filling saline implants and tissue expanders is possible in clinic; it is not an
advantage of using silicone implants.
Chapter 52&Breast Augmentation 397
PREOPERATIVE PLANNING
5. Which of the following is an advantage to using saline versus silicone implants?
B. Historically lower contracture rates.
The benefits of saline compared to silicone are a historically lower contracture rate, adjusting quickly to
body core temperature, leaks are easily detected and safely absorbed by the body, and the sizes are more
customizable. Silicone implants have a more natural feel and appearance. Complete deflation with leak
and wrinkling are disadvantages of saline implants.
1
REFERENCE
1. Gutowski KA, Mesna GT, Cunningham BL. Saline-filled breast implants: a Plastic Surgery Educational Foundation
multicenter outcomes study. Plast Reconstr Surg 1997;100:1019
PREOPERATIVE PLANNING
6. What volume increases volume by one cup size in an average body frame?
B. 125–150 cc.
To increase by one cup size, 125 to 150 cc is required. However, larger body frames may require larger
implant volumes to increase cup size.
1,2
REFERENCES
1. Tebbetts JB, Adams WP. Five critical decisions in breast augmentation using five measurements in 5 minutes. The
high five decision support process. Plast Reconstr Surg 2005;116:2005
2. Tebbetts JB. Dual plane breast augmentation: optimizing implant-soft-tissue relationships in a wide range of
breast types. Plast Reconstr Surg 2001;107:1255
PREOPERATIVE PLANNING
7. What is an advantage to using textured implants over smooth implants?
C. Lower contracture rate.
Textured implants have lower contracture rates due to surface disorienting collagen deposition. It also
has less migration and implant rotation, which make intraoperative positioning of implant critical as
textured surface resists migration or movement in pocket. Smooth implants form thinner capsules and
are less palpable. Textured implants require precise pocket dissection, are more palpable, develop
traction rippling more commonly, and have a greater association with breast implant associated
anaplastic large cell lymphoma (BIA-ALCL) based on current data.
1,2,3
REFERENCES
1. Rohrich RJ, Kenkel JM, Adams WP. Preventing capsular contracture in breast augmentation: in search of the Holy
Grail. Plast Reconstr Surg 1999;103:1759
2. Doren EL, Miranda RN, Selber JC, et al. Breast implant-associated anaplastic large cell lymphoma: a systematic
review. JAMA Surg 2019;154(12):1161–1168
3. Leberfinger AN, Behar BJ, Williams NC, Rakszawski KL, Potochny JD, Mackay DR. Breast implant-associated anaplastic large cell lymphoma: a comprehensive review. Plast Reconstr Surg 2017;139(3):682e–691e
PREOPERATIVE PLANNING
8. Which type of implant has the lowest rate of contracture?
C. Polyurethane-covered.
Polyurethane-covered implants have the lowest rate of contractures (<1% over 10 years) but these were
pulled from US market because polyurethane breaks down as carcinogenic compound, although levels are
likely insignificant.
1,2
REFERENCES
1. Collis N, Coleman D, Foo IT, et al. Ten-year review of a prospective randomized controlled trial of textured versus
smooth subglandular silicone gel breast implants. Plast Reconstr Surg 2000;106:786