Question 6#

Which statement about the TRAM flap is true?

A. Fat necrosis is seen in the free flap as commonly as in the pedicled flap

Is contraindicated in the presence of a Pfannenstiel scar.

References:

1. Hamdi M, Hall-Findlay EJ. Pedicle choices in breast reduction. In: Vertical scar mammaplasty. Hamdi M, Hammond DC, Nahai F, Eds. Berlin, Germany: SpringerVerlag, 2005: 11-6.

Question 7#

Which of the following MUST be adhered to when undertaking a breast reduction?

A. The new nipple position should always be located at 20-22cm from the suprasternal notch

None of these options is correct. Most aesthetic measurements of the breast are based on Penn’s publication which are only a guide. In a group of 20 women with aesthetically perfect breasts, he found the ideal position of the nipple is located at 21cm from the SSN. Mid-humeral measurement was popularised by Lassus. Locating the new nipple position at 4-5cm higher than the IMF is used in inverted-T mammaplasty and does not apply to all techniques. Pitanguy put the nipple where one index in the IMF touches the other index crossing the breast parenchyma. All these measurements can be used as a good starting point; however, more variations have been demonstrated by many other surgeons. Surgeons need to drop the nipple position at least 2cm from their usual design with the inverted-T approach. Vertical mammaplasty creates a significant breast projection and the nipple will have the illusion of being higher because of the increased slope of the upper portion of the breast. Therefore, the new nipple position needs to be lowered about 2cm below what one would use to mark in the inverted-T approach.

References:

1. Penn J. Breast reduction. Br J Plast Surg 1955; 7: 357.
2. Hall-Findlay EJ, A simplified vertical reduction mammaplasty: shortening the learning curve. Plast Reconstr Surg 1999; 104(3): 748-59.

Question 8#

Which of the following contributes to the blood supply of the breast?

A. Lateral thoracic artery

Question 9#

In the hands of an inexperienced plastic surgeon, vertical scar mammaplasty is more predictable except: 

A. In breast reduction of less than 500g per side

In a patient after massive weight loss (MWL). The ideal candidate for vertical scar mammaplasty is one who has simple breast ptosis or who requires gland reduction of 400-500g or less. A patient of stable weight is preferable to an obese patient whose weight is constantly fluctuating. Young patients usually have good quality skin. Juvenile patients are more prone to unpredictable and hypertrophic scars. The vertical scar often has the least risk as compared with the peri-areolar and the horizontal scars, but all efforts should be undertaken to keep scars as short as possible. Patients with large breasts, where the amount of tissue resection exceeds 1000g per side, and older patients, where skin has lost its elasticity, are not good candidates for this technique. Patients after massive weight loss are better managed with an inverted-T scar technique. Using vertical scar mammaplasty will lead to early ptosis, residual skin excess, and lack of projection of the breast due to flaccid and loose tissue.

References:
1. Hamdi M, Hall-Findlay EJ. Pedicle choices in breast reduction. In: Vertical scar mammaplasty. Hamdi M, Hammond DC, Nahai F, Eds. Berlin, Germany: SpringerVerlag, 2004.

Question 10#

The most reliable technique of breast reduction to preserve NAC sensitivity is:

A. The superior pedicle

Würinger’s septum-based pedicle. Using a central pedicle or laterally based inferior pedicle technique resulted in loss of nipple sensitivity in 9.5% of breasts and correlated with increasing breast size and amount of resection. When <440g per breast was resected, nipple sensation was retained 100% of the time. Loss of sensation to the nipple can occur after any kind of breast reduction, but some subgroups of patients and reduction techniques are associated with a higher incidence of nipple sensitivity loss than others. Inferior pedicle techniques retain NAC sensitivity better than the superior pedicle techniques during the first 3 months postoperatively. At 6 months postoperatively NAC sensation was comparable between the two techniques. Medial pedicle techniques seem to retain similar NAC sensation as compared with the inferior pedicle technique. Mammaplasty techniques which are based on Würinger’s septum seem to preserve sensation to the NAC better. This is a ligamentous suspension of the breast consisting of a horizontal septum attaching the NAC to the thoracic wall at the level of the fifth rib. It also includes branches and perforators from the intercostal, thoraco-acromial, and lateral thoracic vessels as well as the deep branch of the 4th intercostal nerve. Including the septum in a lateral pedicle technique will provide better NAC sensitivity than a traditional superior or inferior pedicle technique.

References:

1. Gonzalez F, Brown FE, Gold ME, Walton RL, Shafer B. Preoperative and postoperative nipple-areola sensibility in patients undergoing reduction mammaplasty. Plast Reconstr Surg 1993; 92(5): 809-14.
2. Hamdi M, Greuse M, DeMey A, Webster MHC. A prospective quantitative comparison of breast sensation after superior and inferior pedicle mammaplasty. Br J Plast Surg 2001; 54(1): 39-42.
3. Nahabedian MY, Mofid MM. Viability and sensation of the nipple-areola complex after reduction mammaplasty. Ann Plast Surg 2002; 49(1): 24-31.
4. Würinger E, Mader N, Posch E, Holle J. Nerve and vessel supplying ligamentous suspension of the mammary gland. Plast Reconstr Surg 1998; 101(6): 1486-93.
5. Hamdi M, Blondeel P, Van de Sijpe K, Van Landuyt K, Monstrey S. Evaluation of nipple-areola complex sensitivity after the latero-central glandular pedicle technique in breast reduction. Br J Plast Surg 2003; 56(4): 360-4.