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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_813_Библиотеки_им_академика_М_И_Перельмана.pdf
418 Part VIII&Breast Surgery
Fig. 55.1 Algorithm for workup and treatment of recurrent mammary hypermastia. (Source: Secondary breast reduc-
tion. In: Janis J, ed. Essentials of Aesthetic Surgery. 1st Edition. New York: Thieme; 2018.)
REFERENCE
1. Hammond DC, Loffredo M. Breast reduction. Plast Reconstr Surg 2012;129:829e
Chapter 55&Breast Reduction 419
SURGICAL JUDGMENT
10. A key principle to maintaining vascularity to the nipple-areolar complex during re-reduction includes which
of the following?
B. Deepithelializing around the nipple-areolar complex.
Breast re-reduction can be performed safely and predictably, even when the previous technique is not
known provided the following four key principles are followed
1. Nipple-areolarcomplex can be elevated by deepithelializationrather than re-creating or developing a new
pedicle.
2. Breast tissue is removed where it is in excess, usually inferiorly and laterally.
3. Resection complemented with liposuction to elevate the bottomed-out inframammary fold.
4. Skin should not be excised horizontally below the inframammary fold.
1
:
REFERENCE
1. Losee JE, Cladwell EH, Serletti JM. Secondary reduction mammaplasty: is using a different pedicle safe? Plast
Reconstr Surg 2000;106:1004
SURGICAL TECHNIQUE
11. Wetting solution in breast reduction surgery should be infiltrated into which of the following areas?
A. Retroglandular space and peri-incisional.
Two studies looked at the effects of wetting solution in breast reduction surgery. In both studies, wetting
solution was infiltrated in the retroglandular space and along the incision markings. You do not want to
infiltrate the wetting solution around the pedicle of choice.
1,2
REFERENCES
1. WilminkH, Spauwen PH, Hartman EH, et al. Preoperative injection using a diluted anesthetic/ adrenaline solution
significantly reduces blood loss in reduction mammaplasty. Plast Reconstr Surg 1998;102:1913
2. Samdal F, Serra M, Skolleborg KC. The effects of infiltration with adrenaline on blood loss during reduction
mammaplasty: an early survey. Scand J Plast Reconstr Hand Surg 1992;26:211
SURGICAL JUDGMENT
12. Strategies for reducing the tension in the T region of an inverted-T skin excision breast reduction include
which of the following?
C. Leaving a small wedge of skin at the T region closure site.
Strategies to reduce tension at the T region of an inverted-T skin excision breast reduction include leaving a
small wedge of skin at the T region closure site (Fig. 55.2), avoiding superior keyhole angles of >60
degrees, and keeping vertical limbs at least 7 cm in length.
1
Fig. 55.2 A small wedge of skin at the site of closure limits tension at the final closure. (Source: Inverted-T skin exci-
sion. In: Janis J, ed. Essentials of Aesthetic Surgery. 1st Edition. New York: Thieme; 2018.)
420 Part VIII&Breast Surgery
REFERENCE
1. Ribeiro L, Accorsi A, Buss A, et al. Creation and evolution of 30 years of the inferior pedicle in reduction
mammaplasties. Plast Reconstr Surg 2002;110:960
SURGICAL TECHNIQUE
13. The use of closed suction drains in breast reductions is associated with which of the following?
D. No difference in complications or hematomas.
Several studies have examined the use of closed suction drains in breast reduction surgeries. No study
has ever demonstrated lower complication or hematoma rates with the use of drains.
1,2,3
REFERENCES
1. Wrye SW, Banducci DR, Mackay D, et al. Routine drainage is not required in reduction mammaplasty. Plast
Reconstr Surg 2003;111:113
2. Corion LU, Smeulders MJ, van Zuijlen PP, et al. Draining after breast reduction: a randomized controlled interpatient study. J Plast Reconstr Aesthet Surg 2009;62:865
3. Matarasso A, Wallach SG, Rankin M. Reevaluating the need for routine drainage in reduction mammaplasty. Plast
Reconstr Surg 102:1917, 1998
SURGICAL JUDGMENT
14. When is pathological examination of excised breast tissue warranted?
A. All specimens should undergo pathological examination.
The incidence of breast cancer in reduction specimens is reported at 0.6 to 1.8%; therefore, all
specimens should undergo pathological examination. Additionally, a new baseline mammogram should
be obtained 1 year post breast reduction.
1
REFERENCE
1. Lemmon JA. Reduction mammaplasty and mastopexy. Sel Read Plast Surg 2007;10(19)
56. Gynecomastia
Ira L. Savetsky
See Essentials of Aesthetic Surgery, pp. 789–796
INDICATIONS AND CONTRAINDICATIONS
1. Which of the following is true regarding neonatal and pubertal cases of gynecomastia?
A. Neonatal cases typically resolve within weeks while pubertal cases typically resolve within 2 years without
treatment.
B. Neonatal cases typically resolve within 2 years without treatment while pubertal cases typically resolve
within weeks.
C. Neonatal cases typically resolve within weeks while pubertal cases typically don’t resolve and require
treatment.
D. Neonatal cases typically don’t resolve and require treatment while pubertal cases typically resolve within 2
years without treatment.
E. Neonatal and pubertal cases both don’t resolve.
INDICATIONS AND CONTRAINDICATIONS
2. Patients with Klinefelter syndrome (karyotype 47, XXY) have how much of higher incidence of male breast
cancer compared to X Y karyotype individuals?
A. 2×.
B. 10×.
C. 25×.
D. 50×.
E. 75×.
INDICATIONS AND CONTRAINDICATIONS
3. What is the percentage of the prevalence of Klinefelter syndrome in males with breast cancer?
A. 2%.
B. 7.5%.
C. 20%.
D. 40%.
E. 70%.
INDICATIONS AND CONTRAINDICATIONS
4. A 12-year-old boy is brought in by his family for 3-month development of breast tissue. He is otherwise
healthy. On examination, he has Grade 2 bilateral symmetric gynecomastia. The plan is observation. After
how many months of persistent hypertrophic breast tissue is surgical treatment typically warranted?
A. 3 months.
B. 6 months.
C. 12 months.
D. 18 months.
E. 24 months.
INDICATIONS AND CONTRAINDICATIONS
5. What percentage of pubertal boys are affected with gynecomastia?
A. 5%.
B. 20%.
C. 40%.
D. 60%.
E. 90%.
422 Part VIII&Breast Surgery
ETIOLOGY
6. Which of the following is the most common etiology of gynecomastia?
A. Idiopathic.
B. Physiologic.
C. Pathological.
D. Pharmacologic.
E. Malignant.
ETIOLOGY
7. Which of the following histologic changes are seen with gynecomastia present for more than 1 year?
A. Florid.
B. Increased cellular stroma and ducts.
C. Intermediate.
D. Mix of florid and fibrous patterns.
E. Fibrous.
PREOPERATIVE EVALUATION
8. Which of the following represents Grade III gynecomastia?
A. Minimal hypertrophy (<250 g) and no ptosis.
B. Moderate hypertrophy (250–500 g) and no ptosis.
C. Severe hypertrophy (>500 g) and grade I ptosis.
D. Severe hypertrophy (>500 g) and grade II ptosis.
E. Severe hypertrophy (>500 g) and grade III ptosis.
TECHNIQUE
9. When using ultrasound-assisted liposuction to treat gynecomastia, which of the following is the reason why
the subareolar region requires more treatment?
A. Increased adipose tissue.
B. Increased glandular tissue.
C. Increased ductal tissue.
D. Increased stromal tissue.
E. Increased fibrous tissue.
TECHNIQUE
10. Which of the following is a treatment endpoint when using ultrasound-assisted liposuction to treat
gynecomastia?
A. Until you see skin redness.
B. Volume of lipoaspirate.
C. Loss of resistance.
D. Pinch and contour assessment.
E. Percentage power of ultrasound-assisted liposuction.
TECHNIQUE
11. Which of the following is a treatment endpoint when using suction-assisted liposuction to treat
gynecomastia?
A. Until you see skin redness.
B. Volume of lipoaspirate.
C. Loss of resistance.
D. Pinch and contour assessment.
E. Suction power of suction-assisted liposuction in mmHg.
Chapter 56&Gynecomastia 423
TECHNIQUE
12. How long after performing ultrasound-assisted liposuction should a delayed skin excision be performed?
A. 4–6 weeks.
B. 3–6 months.
C. 6–9 months.
D. 18 months.
E. 2 years.
POSTOPERATIVE CARE
13. What is the incidence of breast cancer in adolescents on pathologic examination of specimen after gyneco-
mastia surgery?
A. ≤1%.
B. 5%.
C. 10%.
D. 20%.
E. 40%.
OUTCOMES
14. What is the most common complication after an excision-only technique?
A. Hematoma.
B. Seroma.
C. Skin necrosis.
D. Nipple necrosis.
E. Infection.
424 Part VIII&Breast Surgery
Answers
INDICATIONS AND CONTRAINDICATIONS
1. Which of the following is true regarding neonatal and pubertal cases of gynecomastia?
A. Neonatal cases typically resolve within weeks while pubertal cases typically resolve within 2 years
without treatment.
Typically, neonatal and pubertal cases resolve with expectant management. Neonatal cases resolve within
several weeks. In pubertal cases, 75% of cases resolved within 2 years without treatment.
REFERENCES
1. Wise GJ, Roorda AK, Kalter R. Male breast disease. J Am Coll Surg 2005;200:255
2. Shulman DI, Francis GL, Palmert MR, et al; Lawson Wilkins Pediatric Endocrine Society Drug and Therapeutics
Committee. Use of aromatase inhibitors in children and adolescents with disorders of growth and adolescent
development. Pediatrics 2008;121:e975
INDICATIONS AND CONTRAINDICATIONS
2. Patients with Klinefelter syndrome (karyotype 47, XXY) have how much of higher incidence of male breast
cancer compared to X Y karyotype individuals?
D. 50×.
Patients with Klinefelter syndrome (karyotype 47, XXY) have a 50× higher incidence of male breast cancer.
1,2
1,2
REFERENCES
1. HultbornR, Hanson C, Köpf I, et al. Prevalence of Klinefelter's syndrome in male breast cancer patients. Anticancer
Res 1997;17:4293
2. Brinton LA. Breast cancer risk among patients with Klinefelter syndrome. Acta Paediatr 2011;100:814
INDICATIONS AND CONTRAINDICATIONS
3. What is the percentage of the prevalence of Klinefelter syndrome in males with breast cancer?
B. 7.5%.
The prevalence of Klinefelter syndrome in males with breast cancer is 7.5%.
1,2
REFERENCES
1. HultbornR, Hanson C, Köpf I, et al. Prevalence of Klinefelter's syndrome in male breast cancer patients. Anticancer
Res 1997;17:4293
2. Brinton LA. Breast cancer risk among patients with Klinefelter syndrome. Acta Paediatr 2011;100:814
INDICATIONS AND CONTRAINDICATIONS
4. A 12-year-old boy is brought in by his family for 3-month development of breast tissue. He is otherwise
healthy. On examination, he has Grade 2 bilateral symmetric gynecomastia. The plan is observation. After
how many months of persistent hypertrophic breast tissue is surgical treatment typically warranted?
C. 12 months.
The presence of hypertrophic breast tissue for >12 months typically warrants surgical treatment because
of fibrotic transformation.
1,2
REFERENCES
1. Banyan GA, Hajdu SI. Gynecomastia: clinicopathologic study of 351 cases. Am J Clin Pathol 1972;57:431
2. Courtiss EH. Gynecomastia: analysis of 159 patients and current recommendations for treatment. Plast Reconstr
Surg 1987;79(5):740–753
Chapter 56&Gynecomastia 425
INDICATIONS AND CONTRAINDICATIONS
5. What percentage of pubertal boys are affected with gynecomastia?
D. 60%.
About 65% of pubertal boys affected (up to 75% bilateral).
1
REFERENCES
1. Niewoehner CB, Nuttal FQ. Gynecomastia in a hospitalized male population. Am J Med 1984;77:633
ETIOLOGY
6. Which of the following is the most common etiology of gynecomastia?
A. Idiopathic.
Idiopathic is the most common etiology (25%). Physiologic causes include neonatal (influence of maternal
estrogens), pubertal (elevated estradiol/estrogen ratio), and senile (peripheral conversion of testosterone to
estrogen by aromatase). Pathologic causes include cirrhosis, kidney failure, testicular/adrenocortical/pituitary
tumors, hypogonadism, hyperthyroidism, adrenal hyperplasia, and bronchogenic carcinoma. Pharmacologic
causes include estrogens, gonadotropins, androgens, antiandrogens, chemotherapy agents, calcium channel
blockers, ACE inhibitors, digitalis, CNS agents, antituberculosis medications, and drugs of abuse.
1,2,3
REFERENCES
1. Banyan GA, Hajdu SI. Gynecomastia: clinicopathologic study of 351 cases. Am J Clin Pathol 1972;57:431
2. Courtiss EH. Gynecomastia: analysis of 159 patients and current recommendations for treatment. Plast Reconstr
Surg 1987;79:740
3. Nuttall FQ. Gynecomastia as a physical finding in normal men. J Clin Endocrinol Metab 1979;48:338
ETIOLOGY
7. Which of the following histologic changes are seen with gynecomastia present for more than 1 year?
E. Fibrous.
Florid histologic pattern is seen when symptoms are present for <4 months; cellular stroma and ducts
are increased. Intermediate histologic pattern is seen when symptoms are present for 4 to 12 months;
there is a mix of florid and fibrous patterns. A fibrous histologic pattern is seen when gynecomastia
present for >1 year; there are minimal ducts but extensive stromal fibrosis.
1
REFERENCE
1. Banyan GA, Hajdu SI. Gynecomastia: clinicopathologic study of 351 cases. Am J Clin Pathol 1972;57:431
PREOPERATIVE EVALUATION
8. Which of the following represents Grade III gynecomastia?
C. Severe hypertrophy (>500 g) and grade I ptosis.
Grade I: Minimal hypertrophy (<250 g) and no ptosis. Grade II: Moderate hypertrophy (250–500 g) and no
ptosis. Grade III: Severe hypertrophy (>500 g) and grade I ptosis. Grade IV: Severe hypertrophy (>500 g) and
grade II or III ptosis.
1
REFERENCE
1. Rohrich RJ, Ha RY, Kenkel JM, et al. Classification and management of gynecomastia: defining the role of ultrasound-assisted liposuction. Plast Reconstr Surg 2003;111:909
TECHNIQUE
9. When using ultrasound-assisted liposuction to treat gynecomastia, which of the following is the reason why
the subareolar region requires more treatment?
E. Increased fibrous tissue.
When utilizing ultrasound-assisted liposuction (UAL) to address gynecomastia, the subareolar region
often requires more attention and specific treatment due to the unique anatomical composition of this
426 Part VIII&Breast Surgery
area, specifically because of the increased concentration of fibrous tissue.
emulsifying fatty tissue, making it easier to suction out. However, the dense and fibrous nature of glandular tissue in the subareolar region can make it more challenging to treat with liposuction alone. In UAL
for gynecomastia, surgeons often combine ultrasound energy with traditional liposuction techniques to
address both the fatty component and the fibrous glandular tissue present in the subareolar region. This
approach helps in selectively targeting the dense glandular tissue while minimizing the risk of contour
irregularities or damage to surrounding structures.
1,2
UAL helps in liquefying and
REFERENCES
1. Rohrich RJ, Ha RY, Kenkel JM, et al. Classification and management of gynecomastia: defining the role of ultrasound-assisted liposuction. Plast Reconstr Surg 2003;111:909
2. Gingrass MK, Shermak MA. The treatment of gynecomastia with ultrasound-assisted lipoplasty. Semin Plast Surg
1999;12:101
TECHNIQUE
10. Which of the following is a treatment endpoint when using ultrasound-assisted liposuction to treat
gynecomastia?
C. Loss of resistance.
The time for each treatment area is recorded. Endpoints for treatment are time and loss of resistance.
Treatment until you see skin redness or pinch test and contour assessments are not the best endpoints
to determine treatment endpoints. The power level on ultrasound-assisted liposuction is not a treatment endpoint.
1,2
REFERENCES
1. Rohrich RJ, Ha RY, Kenkel JM, et al. Classification and management of gynecomastia: defining the role of ultrasound-assisted liposuction. Plast Reconstr Surg 2003;111:909
2. Gingrass MK, Shermak MA. The treatment of gynecomastia with ultrasound-assisted lipoplasty. Semin Plast Surg
1999;12:101
TECHNIQUE
11. Which of the following is a treatment endpoint when using suction-assisted liposuction to treat
gynecomastia?
D. Pinch and contour assessment.
A bimanual technique is necessary for suction-assisted liposuction (SAL) because the nondominant
hand is used to grasp and elevate the breast tissue being treated. Endpoints are determined by pinch
test and contour assessment.
1
The other answer choices are not correct.
REFERENCE
1. Li CC, Fu JP, Chang SC, et al. Surgical treatment of gynecomastia: complications and outcomes. Ann Plast Surg
2012;69(5):510–515
TECHNIQUE
12. How long after performing ultrasound-assisted liposuction should a delayed skin excision be performed?
C. 6–9 months.
Staged skin excision is performed 6 to 9 months after ultrasound-assisted liposuction (UAL) to allow
maximal skin retraction.
1
REFERENCE
1. Rohrich RJ, Ha RY, Kenkel JM, et al. Classification and management of gynecomastia: defining the role of ultrasound-assisted liposuction. Plast Reconstr Surg 2003;111:909
Chapter 56&Gynecomastia 427
POSTOPERATIVE CARE
13. What is the incidence of breast cancer in adolescents on pathologic examination of specimen after gyneco-
mastia surgery?
A. ≤1%.
According to a literature review, the incidence of breast cancer risk in adolescents with gynecomastia is
1% (maximum). Some authors argue that routine histopathologic examination incurs negative
productivity costs. However, the prevalence of malignancies in gynecomastia specimens increases with
patient's age. Thus, histologic evaluation is recommended for all patients with pathologic
gynecomastia.
1,2,3
REFERENCES
1. Kwan D, Song DH. Discussion. Breast cancer incidence in adolescentmales undergoing subcutaneous mastectomy
for gynecomastia: is pathologic examination justified? A retrospective and literature review. Plast Reconstr Surg
2011;127:8
2. Senger JL, Chandran G, Kanthan R. Is routine pathologicalevaluation of tissue from gynecomastia necessary?A 15year retrospective pathological and literature review. Can J Plast Surg 2014;22:112
3. Lapid O, Jolink F, Meijer SL. Pathological findings in gynecomastia: analysis of 5113 breasts. Ann Plast Surg
2015;74:163
OUTCOMES
14. What is the most common complication after an excision-only technique?
B. Seroma.
In a recent study with 312 consecutively treated cases who underwent subcutaneous mastectomy, there
were 6 seromas (2%) and 3 hematomas (1%).
of dead space under the skin, there tends to be a higher rate of seromas as complications in these types
of cases. Without any skin removal and proper surgical technique, the rates of skin necrosis and nipple
necrosis are <1% given the intact blood supply to the skin through the subder mal plexus. The rate of
infections after gynecomastia surgery is 1% as well, which is in line with other plastic surgery
procedures.
1
Given that in the excision-only technique there is an area
REFERENCE
1. Innocenti A, Melita D, Mori F, et al. Management of gynecomastia in patients with different body types: considerations on 312 consecutive treated cases. Ann Plast Surg 2017;78:492