Just as the surgical management of breast cancer has evolved, so too has the field of breast surgery. Patient and surgeon expectations are no longer limited to recreating a breast mound but instead to recreate esthetically pleasing, symmetrical breasts, thus improving quality of life and body image. The number of women undergoing reconstruction continues to increase each year. Breast reconstruction must be accomplished without handicapping any future treatment for the breast cancer and keeping the operation relatively simple, reproducible, and, most important, safe. The surgical changes in the treatment of breast cancer have changed dramatically from the Halsted radical mastectomy to the breast-conserving therapies of today. To perform breast reconstructions or breast reductions, one must know the ideal esthetics of the breasts, the diagnosis, and the surgical reconstructive objectives. This chapter covers breast reconstruction after mastectomies, breast reductions, and oncoplastic breast surgery, an evolving field that combines all available techniques. The surgical description of common reconstructive techniques is described.

BACKGROUND:Despite the knowledge of alternate lymphatic draining patterns of the breast, routine evaluation of the internal mammary lymph node basin is still not considered standard of care. The advent of microsurgical breast reconstruction using the internal mammary vessels as recipients, however, has allowed sampling of internal mammary lymph nodes with technical ease, thus revisiting their role in breast cancer management. In the present study, the authors reviewed their experience with this practice.METHODS:A retrospective analysis of patients who underwent internal mammary lymph node biopsy at the time of autologous breast reconstruction using the internal mammary vessels between 2004 and 2012 was performed. Parameters of interest included patient age, timing of reconstruction (immediate versus delayed), disease stage, and pathologic findings of internal mammary lymph nodes.RESULTS:A total of 264 autologous breast reconstructions using the internal mammary vessels were performed in 204 patients with a median age of 44.5 years. The majority of reconstructions were immediate [n = 211 (79.9 percent)]. Seventy-two percent of patients had either stage I [72 patients (35.3 percent)] or stage II disease [75 patients (36.8 percent)]. Six patients were found to have internal mammary lymph node metastasis. Stage migration and alteration in adjuvant therapy occurred in all patients.CONCLUSION:Internal mammary lymph node sampling at the time of autologous breast reconstruction using the internal mammary system should become routine practice, as the morbidity associated with internal mammary lymph node harvest is low and the impact in cases of nodal involvement is quite substantial.CLINICAL QUESTION/LEVEL OF EVIDENCE:Therapeutic, IV.

Background Comprehensive aesthetic surgery training continues to be a challenge for residency programs. Our residency program developed a rhinoplasty-based objective structured clinical examination (OSCE) based upon validated methods as part of the residency education curriculum. We report our experience with the rhinoplasty-based OSCE and offer guidance to its incorporation within residency programs.Methods The encounter involved resident evaluation and operative planning for a standardized patient desiring a rhinoplasty procedure. Validated OSCE methods currently used at our medical school were implemented. Residents were evaluated on appropriate history taking, physical examination, and explanation to the patient of treatment options. Examination results were evaluated using analysis of variance (statistical significance P< 0.05).Results Twelve residents completed the rhinoplasty OSCE. Medical knowledge assessment showed increasing performance with clinical year, 50% versus 84% for postgraduate year 3 and 6, respectively (P< 0.005). Systems-based practice scores showed that all residents incorrectly submitted forms for billing and operative scheduling. All residents confirmed that the OSCE realistically represents an actual patient encounter. All faculty confirmed the utility of evaluating resident performance during the OSCE as a useful assessment tool for determining the Next Accreditation System Milestone level.Conclusions Aesthetic surgery training for residents will require innovative methods for education. Our examination showed a program-educational weakness in billing/coding, an area that will be improved upon by topic-specific lectures. A thoroughly developed OSCE can provide a realistic educational opportunity to improve residents' performance on the nonoperative aspects of rhinoplasty and should be considered as an adjunct to resident education.

Background: Our institution has incorporated the use of objective structured clinical examinations (OSCE) in our residency curriculum. The OSCE provides trainee education and evaluation while addressing the six Accreditation Council for Graduate Medical Education (ACGME) core competencies required within training programs. We report our program's experience with the first cleft OSCE ever conducted.Methods: A validated method for administration of OSCEs currently used at our medical school was utilized for residents in postgraduate years (PGYs) 3 through 6. The video-recorded patient encounter involved a 1-month-old newborn with a unilateral cleft lip and palate and used standardized patient actors as parents. A post-encounter written exam assessed medical knowledge. A questionnaire regarding the utility of the exercise was administered to residents after the OSCE. Results were evaluated using analysis of variance (P < .05).Results: There was a positive correlation with increasing level of training in terms of medical knowledge (P < .04). Residents in PGY-3 and PGY-4 demonstrated lower understanding of the surgical markings and details of the lip repair compared with those in PGY-5 and PGY-6 (P < .03). All residents performed similarly on evaluation of the remaining ACGME core competencies. All residents agreed that this was a realistic and useful encounter.Conclusion: Results of our cleft OSCE demonstrate that medical knowledge regarding the evaluation, management, and surgical repair of patients is less in midlevel residents. All residents expressed an interest in earlier exposure to pediatric patients in the training period. Although a cleft OSCE does not replace clinical rotations, it is a valuable adjunct to training and evaluation of trainees, particularly for junior residents.