Recommendations for Pathologic Evaluation of Reduction Mammoplasty Specimens: A Prospective Study With Systematic Tissue Sampling.

CONTEXT: - Breast reduction mammaplasty (RMP) for symptomatic macromastia or correction of asymmetry is performed in more than 100 000 patients per year in the United States. The reported incidence of significant pathologic findings (SPF), that is, carcinoma and atypical hyperplasia, ranges from 0.06% to 12.8%. No standard pathology assessment for RMP exists. OBJECTIVES: - To propose standard sampling for microscopic evaluation in RMP specimens, to evaluate the incidence of occult carcinoma and atypical hyperplasia, and to identify clinical risk factors for SPF in patients undergoing RMP. DESIGN: - All RMP specimens from 2006 to 2013 at a single institution were prospectively examined. After baseline gross and microscopic evaluations, each specimen was subjected to systematic additional sampling. The incidence of SPF was tabulated, and variables such as age, specimen weight, previous history of SPF, and results of preoperative mammogram were examined. Clinical follow-up review was also subsequently undertaken. RESULTS: - A total of 595 patients were evaluated. Significant pathologic findings were present in 9.8% (58 of 595) of patients. No cancer was identified in patients younger than 40 years; the rates of carcinoma were 2.4% (14 of 595) in all patients, 3.6% (14 of 392) in patients aged 40 years or older, and 4.3% (10 of 233) in patients aged 50 years or older. No carcinoma or atypical hyperplasia was identified on preoperative mammogram. Increased sampling was associated with a significantly greater frequency of SPF only in patients aged 40 years or older. CONCLUSIONS: - In patients younger than 35 years, gross-only evaluation is sufficient. However, increased sampling may be necessary in patients older than 40 years.

Principles of Breast Re-Reduction: A Reappraisal.

BACKGROUND: This article examines outcomes following breast re-reduction surgery using a random pattern blood supply to the nipple and vertical scar reduction. METHODS: A retrospective review was conducted of patients who underwent bilateral breast re-reduction surgery performed by a single surgeon over a 12-year period. Patient demographics, surgical technique, and outcomes were analyzed. RESULTS: Ninety patients underwent breast re-reduction surgery. The average interval between primary and secondary surgery was 14 years (range, 0 to 42 years). The majority of patients had previously undergone primary breast reduction using an inferior pedicle [n = 37 (41 percent)]. Breast re-reduction surgery was most commonly performed using a random pattern blood supply, rather than recreating the primary pedicle [n = 77 (86 percent)]. The nipple-areola complex was repositioned in 60 percent of patients (n = 54). The mean volume of tissue resected was 250 g (range, 22 to 758 g) from the right breast and 244 g (range, 15 to 705 g) from the left breast. Liposuction was also used adjunctively in all cases (average, 455 cc; range, 50 to 1750 cc). Two patients experienced unilateral minor partial necrosis of the areolar edge but not of the nipple itself (2 percent). CONCLUSIONS: Breast re-reduction can be performed safely and predictably, even when the previous technique is not known. Four key principles were developed: (1) the nipple-areola complex can be elevated by deepithelialization rather than recreating or developing a new pedicle; (2) breast tissue is removed where it is in excess, usually inferiorly and laterally; (3) the resection is complemented with liposuction to elevate the bottomed-out inframammary fold; and (4) skin should not be excised horizontally below the inframammary fold. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Carcinoma and atypical hyperplasia in reduction mammaplasty: increased sampling leads to increased detection. A prospective study.

BACKGROUND: Reduction mammaplasty for symptomatic macromastia or correction of asymmetry is performed more than 100,000 times per year in the United States. The reported incidence of occult breast cancer in reduction mammaplasty ranges from 0.06 to 4.6 percent. No standard pathology assessment for reduction mammaplasty exists. The authors evaluated the incidence of occult carcinoma and atypical hyperplasia in reduction mammaplasty specimens and identified clinical risk factors. Systematic sampling of additional tissue sections was instituted to evaluate the hypothesis that increased sampling would identify more significant pathologic findings. METHODS: All reduction mammaplasty specimens over a 20-month period at a single institution were prospectively examined. All specimens had baseline gross and microscopic evaluations, and then each was subjected to systematic additional sampling. The incidence of significant pathologic findings (carcinoma and atypical hyperplasia) was tabulated. Variables such as age and preoperative mammogram were examined. RESULTS: A total of 202 cases were evaluated. Significant pathologic findings (carcinoma and atypical hyperplasia) were present in 12.4 percent. The rate of carcinoma was 4 percent in all patients (6.2 percent in patients >or=40 years and 7.9 percent in patients >or=50 years). CONCLUSIONS: A significantly higher rate (12.4 percent) of significant pathologic findings was identified in this prospective study compared with published literature. None of the lesions was identified on preoperative mammogram. Age was significantly associated with significant pathologic findings. Increased sampling was associated with significant pathologic findings only in patients 40 years or older, indicating the need for thorough sampling of reduction mammaplasty specimens in patients older than 40.

Bilateral breast reconstruction and the role of prophylactic mastectomy.

Bilateral breast reconstruction may be indicated in women with bilateral cancers, those with unilateral cancer and a high risk of developing a contralateral cancer, or in women who choose bilateral prophylactic mastectomy. Numerous options for reconstruction are available, including TRAM flaps, latissimus dorsi flaps, and saline or silicone gel-filled implants. The discoveries of the BRCA1 and BRCA2 gene mutations and their implications for breast cancer risk have led to renewed interest in prophylactic mastectomy. Recent studies have confirmed that prophylactic mastectomy is effective in reducing breast cancer risk, but the decision to proceed with prophylactic mastectomy must be made on a case-by-case basis.