Multimodality Imaging of the Reconstructed Breast

Abstract

The purpose of this article is to illustrate the imaging characteristics and pathologic findings associated with various types of breast reconstruction in women who have undergone mastectomy to treat breast cancer. As the use of breast reconstruction becomes more prevalent, it is imperative that radiologists interpreting imaging studies identify normal and abnormal imaging findings associated with differing breast reconstruction techniques, recognize imaging manifestation of expected complications, and reliably distinguish these from malignancy.

Fig.1

Pedicled and free TRAM flaps. A) The pedicled flap rotates the abdominal tissue to the chest wall with its blood supply. The pedicled flap contains skin, fatty tissue, and muscle. B) The free flap vessels are ligated and microsurgically anastomosed to the chest vessels. The free flap contains skin, fatty tissue, and vessels.

Fig.2

Abdominal vascular anatomy. The deep vessels are the superior epigastric vessels and the deep inferior epigastric vessels. These vessels have perforators that supply the overlying fat and the skin. The superficial network is supplied by the superficial superior epigastric vessels and the superficial inferior epigastric vessels.

Fig.3

A) LD flap reconstruction. This flap uses the LD muscle and a portion of the overlying skin and fat. The arteries and veins remain attached. B) 52-year-old woman with a history of ductal carcinoma in situ (DCIS), status post mastectomy with reconstruction with a latissimus dorsi flap. Sagittal T1-weighted post-contrast MRI shows the muscle fibers of the flap (thick white arrows). Blood vessels are also noted within the muscle pedicle (dashed white arrow).

Fig.4

Normal appearance of a TRAM flap in a 44-year-old woman with a history of right breast cancer who underwent bilateral mastectomies and bilateral reconstructions with free TRAM flaps. A) Left mediolateral oblique mammogram of the reconstructed breast shows the predominantly fatty appearance with the surgical clips in the posterior region of the flap. B) Longitudinal ultrasound of the TRAM flap demonstrates fatty tissue. C) Chest CT demonstrates the typical changes of TRAM flap reconstructions. The reconstructed breast is fatty. A thin, soft-tissue curvilinear band is seen underneath the skin (white arrow). These bands represent the de-epithelialized abdominal skin of the flap that has been tunneled into position from the abdomen. D) Sagittal T1-weighted post-contrast MRI of the reconstructed breast demonstrates adipose tissue with no evidence of residual mammary tissue. The contact zone between the flap and the native tissue appears as a line of intermediate signal intensity (thin white arrow) parallel to the breast contour. A surgical clip is noted in the posterior region of the reconstructed breast (thick white arrow).

Fig.5

48-year-old woman with DIEP TRAM flap reconstruction in the right breast after mastectomy for right breast cancer. She presented for evaluation of skin redness. Extended field of view ultrasound shows two fluid collections in the right reconstructed breast. In the central region, there is an anechoic fluid collection, consistent with a seroma (thick white arrows). In the medial region, where the skin demonstrated erythema, an irregular complex fluid collection is seen (dashed white arrows). Both collections were drained, yielding brownish fluid from the seroma and purulent material from the complex fluid collection, compatible with an abscess.

Fig.6

58 year-old woman with a history of left breast cancer, status post bilateral mastectomies and reconstructions with DIEP flaps who presents for evaluation of a palpable abnormality. A) Transverse US image in the area of the palpable abnormality shows a 1.7 cm circumscribed, superficial mass with posterior acoustic enhancement (white arrows). B) Power Doppler US shows minimal vascularity in the mass (white arrow). Ultrasound-guided FNA was performed, showing findings compatible with an epidermal inclusion cyst.

Fig.7

Typical fat necrosis in a 53-year-old woman with a history of right breast cancer, status post mastectomy and reconstruction with a muscle-sparing free TRAM flap. A) Axial T1-weighted non-fat saturated MRI demonstrates a fat- containing mass in the upper outer quadrant (white arrows). B) Axial T1-weighted post-contrast MRI shows peripheral enhancement of the fat- containing mass (arrows). C) Extended field of view ultrasound shows a hypoechoic mass with indistinct margins (white arrows).

Fig.8

44-year-old woman with a history of right breast cancer, status post mastectomy and reconstruction with a muscle-sparing free TRAM flap. A) Axial T1-weighted post-contrast MRI demonstrates a 1.3-cm oval enhancing mass in the pre-sternal fat (white arrow). B) Sagittal T1-weighted post-contrast MRI shows the enhancing mass (arrow) with an area of washout kinetics on the computer-aided diagnosis images. C) Longitudinal second-look ultrasound shows a hypoechoic mass with indistinct margins (white arrows). Ultrasound-guided-core biopsy demonstrated fat necrosis.

Fig.9

Implant-based breast reconstruction. After mastectomy, a tissue expander is placed under the muscle and the skin. Increasing amounts of saline are added to the tissue expander in the clinic. The fixed-volume implant is inserted after the tissue expander has been removed.

Fig.10

50-year-old woman with a history of right breast cancer who underwent bilateral mastectomies with implant-based reconstruction. She presented for evaluation of hardening and pain in the reconstructed left breast. A) Extended-field-of-view ultrasound of the left implant demonstrates multiple folds (arrows). B) Sagittal T2-weighted MRI of the left breast shows the spherical appearance of the fibrous capsule and the creased shell (thin white arrow) as well as an implant effusion (thick white arrow). The patient underwent surgery, and capsular contracture was found.

Fig.11

54-year-old woman with a history of DCIS who underwent reconstruction of the left breast with a free TRAM flap presented for evaluation of a palpable mass. A) Mediolateral oblique mammogram shows the post-surgical changes in the reconstructed breast. In the area of the palpable abnormality (triangle), a mass with indistinct margins and calcifications (arrow) is noted. B) Power Doppler ultrasound shows marked vascularity in the mass (arrows). C) Axial T1-weighted post-contrast MRI with fat saturation shows that the malignant mass (arrow) is avidly enhancing. Ultrasound-guided core needle biopsy showed invasive ductal carcinoma. D) PET-CT demonstrates that the malignant mass is hypermetabolic (arrow). The standardized uptake value was 4.3.

Fig.12

53-year-old woman with a history of left breast cancer who underwent mastectomy with TRAM reconstruction presented with a palpable mass in the reconstructed breast. She received radiation therapy for her primary breast cancer. A) Left mediolateral oblique mammogram of the reconstructed breast shows a high-density partially imaged mass (arrows). B) Longitudinal ultrasound shows an 8-cm heterogeneous solid mass (arrows) occupying almost the entire reconstructed breast. C) Chest CT shows the 8-cm solid mass (arrows) adjacent to the chest wall. D) Axial T1-weighted post-contrast MRI depicts the heterogeneous enhancement of this mass (arrows). Surgical excision showed a matrix-producing sarcoma.