Mammaplasty and mastopexy are surgical procedures designed to reshape and reposition the breast tissue. Reduction mammaplasty primarily aims to decrease breast volume and alleviate symptoms such as back pain and postural discomfort, while mastopexy focuses on elevating and reshaping the breast to restore a more youthful contour. Both procedures can be performed separately or in combination to address aesthetic concerns and functional impairments. However, their diagnostic value has become increasingly apparent, as histopathological evaluation of excised tissue frequently reveals incidental findings that have significant clinical and oncological implications. This commentary integrates historical and contemporary evidence, exploring the role of routine histopathological analysis in advancing surgical and oncological care.

In our 2003 study published in Plastic and Reconstructive Surgery, we examined histopathological findings in reduction mammaplasty specimens [1]. The results demonstrated that a substantial percentage of cases presented with benign or premalignant lesions, and occasional occult malignancies. These findings underscored the importance of routine tissue analysis, particularly given the potential for early cancer detection.

This aligns with earlier research by Pitanguy and Torres, who investigated the histopathological aspects of mammary gland tissue in plastic surgery cases, emphasizing the relevance of pathological analysis in breast procedures [2]. Similarly, Freedman et al. identified a notable incidence of occult carcinoma and high-risk lesions in mammaplasty specimens, reinforcing the value of routine evaluation [3]. Degnim et al. further highlighted the unique histologic findings in reduction mammaplasty tissues compared to normal and benign breast disease tissues, supporting the role of histopathology in uncovering clinically significant abnormalities [4].

Usón Junior et al. conducted an analysis of 783 reduction mammaplasty specimens from patients with no previous history of breast cancer. Their study revealed that incidental findings occurred in 20% of the cases. These included benign proliferative lesions, such as fibrocystic changes and atypical ductal hyperplasia (ADH), as well as more concerning findings, such as ductal carcinoma in situ (DCIS), which were detected in 0.3% of the specimens [5]. The detection of these findings emphasizes the potential role of histopathological examination in asymptomatic patients, even those without known risk factors for breast cancer.

In addition to benign proliferative changes, lesions such as atypical lobular hyperplasia (ALH) and lobular carcinoma in situ (LCIS) have been identified as incidental findings in reduction mammaplasty specimens. These lesions carry a higher risk of progression to invasive malignancy, making their identification crucial for the management of breast cancer risk. As reported by Goodwin et al., the management of such findings includes careful follow-up and additional diagnostic work-up to assess the risk of malignancy and determine appropriate interventions [6].

These incidental findings underscore the importance of histopathological examination in breast reduction specimens, not only for providing cosmetic outcomes but also for contributing to early detection and the management of potential malignancies. For patients with atypical findings, close surveillance and timely interventions are recommended to ensure the best outcomes in terms of cancer prevention and management.

Our routine follows the protocol described by Drs. Pitanguy and Torres, initially outlined in 1964 and 2005, respectively [1,2]. Their methodology emphasizes meticulous examination of breast tissue, ensuring that all excised specimens undergo systematic histopathological evaluation. This includes identifying and sending all tissue to pathology, sectioning specimens in thin slices no thicker than 0.5 mm, and carefully inspecting them for any suspicious areas based on appearance or tactile sensation. Suspected areas are then fixed in paraffin and formaldehyde, processed for hematoxylin and eosin staining, and further analyzed microscopically when necessary. By adhering to this established protocol, we enhance diagnostic accuracy and improve patient safety.

Routine histopathological evaluation of aesthetic breast surgery specimens offers significant benefits that outweigh potential drawbacks. One of the primary advantages is the early detection of incidental pathological findings, including atypical hyperplasia, in situ carcinoma, and invasive malignancies that might otherwise go undetected [1-6]. Identifying these lesions at an early stage allows for timely intervention and improved patient outcomes. Additionally, routine evaluation contributes to a better understanding of the prevalence of subclinical breast diseases in aesthetic surgery patients, reinforcing the role of plastic surgeons in comprehensive breast care.

While concerns such as increased costs, extended processing time, and potential patient anxiety may be raised, these are generally outweighed by the clinical value of detecting malignancies at a treatable stage [1-6]. Furthermore, well-established protocols, such as those described by Pitanguy and Torres, help streamline the process, ensuring efficiency without unnecessary resource expenditure [1,2]. Ultimately, the implementation of routine histopathological analysis enhances patient safety, refines surgical planning, and aligns with best practices in oncological vigilance.

While histopathological evaluation should be performed on all excised tissue, the need for additional biopsies should be assessed on a case-by-case basis, depending on the individual patient's clinical history, risk factors, and the specific findings during surgery [7-9]. For patients undergoing aesthetic breast procedures like reduction mammaplasty and mastopexy, we recommend that a thorough histopathological evaluation be performed on all excised tissue, regardless of whether there is an apparent clinical indication for malignancy. This practice allows for the detection of incidental pathological findings that may otherwise go unnoticed, such as atypical hyperplasia, in situ carcinoma, or even invasive breast cancer [1-6].

Regarding the frequency of follow-up biopsies, we recommend that additional biopsies be considered if any suspicious lesions are identified during the initial evaluation or if the patient has a personal or family history of breast cancer [7-9]. Routine follow-up biopsies should not be performed on every patient postoperatively unless clinically indicated (e.g., new symptoms or changes in imaging findings), but regular clinical follow-up, including breast self-examination and mammography, should be maintained to ensure any late-onset abnormalities are detected early. The decision to conduct additional biopsies should always be guided by a multidisciplinary team approach involving plastic surgeons, oncologists, and pathologists.

Ultimately, while routine histopathological evaluation should be performed on all specimens, the frequency of follow-up biopsies should be determined on a case-by-case basis, prioritizing early detection and patient safety.

Identifying patients who would benefit most from comprehensive histopathological evaluation is a critical challenge. Research has identified several key predictive factors that can guide risk stratification and patient selection:

Age

Women over 40 years old have a higher likelihood of significant findings, suggesting the need for targeted screening protocols focused on this age group. This aligns with the growing body of evidence suggesting that reproductive risk factors, such as age, are pivotal in stratifying breast cancer risks [10].

Family history

A family history of breast or ovarian cancer necessitates increased vigilance, as these patients are at a heightened risk of developing breast cancer. This factor calls for more intensive monitoring and early intervention.

Breast density

Higher breast density not only increases the risk of incidental findings but also complicates preoperative imaging, as dense tissue can obscure lesions. This requires the use of advanced imaging techniques to ensure accurate assessment.

A risk-stratified approach to histopathological protocols can optimize resource utilization while ensuring high-risk individuals receive the most comprehensive care. This approach is in line with recent efforts to implement risk-stratified breast screening programs that aim to tailor care based on individual risk profiles [11].

Modern advances in molecular pathology have revolutionized the evaluation of breast tissue. Techniques such as next-generation sequencing (NGS) and genomic assays now enable the characterization of atypical findings with unprecedented precision. For instance, genomic profiling of ductal carcinoma in situ (DCIS) specimens can predict the likelihood of progression to invasive carcinoma, informing individualized patient management [12]. These advancements have significantly enhanced the understanding of tumor biology, offering a more detailed view of molecular alterations in breast cancer.

Genetic analyses of reduction mammaplasty specimens have also identified mutations in genes such as TP53, BRCA1/2, and PIK3CA. These mutations, while not always indicative of malignancy, can provide valuable insights into a patient’s cancer risk and inform personalized screening and prevention strategies. Mutations in BRCA1/2, for example, are well-known for their association with hereditary breast cancer, and their identification can lead to more focused surveillance and preventative care in at-risk individuals [13]. Furthermore, mutations in the PIK3CA gene, frequently observed in breast cancer, can also be detected in benign tissue, which can be important for understanding a patient's overall risk profile.

The integration of molecular pathology with clinical practice continues to enhance the precision of breast cancer diagnosis and management, offering personalized care for patients and improving clinical outcomes. The growing role of genomic testing is transforming decision-making, particularly in radiation therapy, by enabling better prediction of treatment responses and reducing unnecessary interventions [14].

The management of incidental findings requires close collaboration between plastic surgeons, oncologists, radiologists, and pathologists. A standardized, multidisciplinary approach is essential to ensure optimal patient care and outcomes. Key components of this approach, include:

Preoperative counseling

Patients should be informed about the possibility of incidental findings and their potential implications for long-term health. This communication helps patients understand the risks and prepares them for potential further investigations or treatments [15].

Postoperative management

Abnormal findings should trigger a multidisciplinary review. This review should involve oncological evaluation and genetic counseling to ensure comprehensive management of any identified risks [16].

Tailored srveillance

Patients with premalignant lesions should be enrolled in surveillance programs that involve regular imaging and clinical follow-up. Such programs are critical for early detection of any progression and to guide timely interventions, thereby optimizing patient outcomes [15,16].

This multidisciplinary approach ensures that all aspects of patient care are addressed and helps optimize survival and quality of life for patients facing incidental findings.

The discovery of incidental findings during elective procedures, such as reduction mammaplasty, presents unique ethical challenges. These include:

Informed consent

Patients must be thoroughly informed about the rationale for routine histopathology and the potential implications of incidental findings. As highlighted by Ells and Thombs, clear communication is critical to ensure patients understand the risks and benefits associated with the procedure, including the possibility of unexpected findings [17].

Psychological impact

Unexpected diagnoses, even of premalignant conditions, can lead to significant anxiety. McKenzie et al. discuss how such diagnoses may cause emotional distress, which necessitates providing psychological support to patients throughout the process, helping them manage the potential mental health implications [18].

Cost-Effectiveness

Although the incidence of malignancy is low, the potential for life-saving early detection often justifies the inclusion of routine histopathological evaluation in standard practice. As noted by Ells and Thombs, the cost-effectiveness of this practice lies in its ability to identify conditions early, allowing for timely intervention [17].

These ethical and psychological factors must be carefully considered in the management of incidental findings to ensure both effective patient care and psychological well-being.

Several avenues for research and innovation could further enhance the diagnostic and therapeutic value of aesthetic breast surgery:

Artificial intelligence in pathology

Machine learning algorithms have the potential to significantly enhance the accuracy and efficiency of histopathological evaluations. These advanced technologies can identify subtle patterns that may indicate malignancy, improving diagnostic precision. As Försch et al. suggest, the integration of artificial intelligence into pathology could streamline the diagnostic process and aid pathologists in detecting conditions that might otherwise be overlooked [19]. Furthermore, McGenity et al. demonstrate through a systematic review and meta-analysis that AI in digital pathology has shown considerable diagnostic test accuracy, further solidifying its role in supporting pathologists with more reliable and timely diagnoses [20]. This technological advancement holds promise for transforming pathology by improving both the speed and quality of diagnostic outcomes.

Enhanced imaging modalities

Advances in imaging technologies, particularly high-resolution MRI, have the potential to significantly improve preoperative risk assessments in breast cancer. Qi et al. highlight how these enhanced imaging modalities enable better tumor characterization, which can reduce the reliance on postoperative histopathology [21]. Additionally, Qu et al. demonstrate the effectiveness of an unsupervised learning model based on CT radiomics features in accurately predicting axillary lymph node metastasis in breast cancer patients, further underscoring the role of AI and imaging in advancing diagnostic capabilities [22]. Urbano et al. also emphasize the impact of new advances in both breast cancer pathology and imaging, noting how these technologies enhance the precision and reliability of diagnostic processes [23]. By integrating AI-driven insights from radiomics with advanced imaging techniques, the diagnostic process can be optimized, leading to more accurate decision-making and improved patient outcomes. The combination of AI in pathology with advanced imaging technologies promises to revolutionize the field, providing faster, more precise, and comprehensive diagnostic solutions.

Longitudinal studies

Further research is needed to quantify the long-term outcomes of patients with incidental findings, including progression rates and the impact of early intervention.

The routine histopathological evaluation of aesthetic breast surgery specimens represents a cornerstone of modern surgical practice, offering opportunities for early cancer detection and personalized care. By integrating advancements in molecular pathology, risk stratification, and interdisciplinary collaboration, we can maximize the oncological and clinical benefits of this widely performed procedure.