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Tissue Transfer Reconstruction Imaging
Shafik N. Wassef, MD; Wendie A. Berg, MD, PhD, FACR, FSBI
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KEY FACTS

  • Terminology

    • Imaging

      • Top Differential Diagnoses

        • Clinical Issues

          TERMINOLOGY

          • Abbreviations

            • Transverse rectus abdominis myocutaneous (TRAM)
            • Gluteal free flap, inferior gluteal artery perforator (IGAP)
            • Superior gluteal artery perforator (SGAP) flap
          • Synonyms

            • Neobreast
            • Autologous reconstruction
          • Definitions

            • Autologous breast tissue reconstruction
              • Flaps may be used alone or in combination with breast implant (usually silicone)
              • Perforator-only flaps
                • Include overlying fat and skin
                • No muscle loss: Minimal functional impairment, ↓ postoperative stay
              • Myocutaneous flaps
                • Include overlying fat and tissue as well as muscle pedicle
                • Muscle loss, donor site weakening/hernias
              • Recipient vessels: Internal mammary and thoracodorsal
            • Myocutaneous and related flaps
              • Delayed contralateral TRAM reconstruction not option: Bilateral TRAM reconstruction can only be performed at time of initial TRAM
                • Requires sufficient abdominal fat to create suitable neobreast volume
              • TRAM flaps
                • Pedicled TRAM
                  • Portion of contralateral rectus abdominis muscle, overlying subcutaneous tissue, and skin
                  • Blood supply from superior epigastric vessels
                • Free TRAM
                  • Created to improve blood supply; limit extensive dissection of full TRAM pedicle flap procedure
              • Latissimus dorsi myocutaneous (LDM) flap
                • Portion of ipsilateral latissimus dorsi muscle and overlying subcutaneous tissue
                • May require implant + flap for adequate volume; AlloDerm sometimes used as sling for implant
            • Perforator-only flap
              • Superficial inferior epigastric perforator (SIEP)
                • Skin/subcutaneous tissue only; perforating vessels from superficial inferior epigastric artery
              • Deep inferior epigastric perforator (DIEP)
                • Based on deep inferior epigastric vessels with advent of microvascular surgery
              • Gluteal free flap
                • Skin and subcutaneous tissue
                • Technically most challenging
                • Staged procedure if bilateral
            • Autologous fat transfer/graft
              • Used to smooth contour irregularities in reconstructed breast or lumpectomy site
              • Liposuction fat, prepare cells, inject
              • Substantial risk of fat necrosis

          IMAGING

          • General Features

            • Imaging Recommendations

              • Mammographic Findings

                • Ultrasonographic Findings

                  • MR Findings

                    • CT Findings

                      DIFFERENTIAL DIAGNOSIS

                        PATHOLOGY

                        • General Features

                          • Gross Pathologic & Surgical Features

                            • Microscopic Features

                              CLINICAL ISSUES

                              • Demographics

                                • Natural History & Prognosis

                                  • Treatment

                                    DIAGNOSTIC CHECKLIST

                                    • Consider

                                      • Image Interpretation Pearls

                                        Selected References

                                        1. Bennett KG et al: Comparison of 2-year complication rates among common techniques for postmastectomy breast reconstruction. JAMA Surg. ePub, 2018
                                        2. Kwok AC et al: Immediate unilateral breast reconstruction using abdominally based flaps: analysis of 3,310 cases. J Reconstr Microsurg. 35(1):74-82, 2018
                                        3. Noroozian M et al: Use of screening mammography to detect occult malignancy in autologous breast reconstructions: a 15-year experience. Radiology. 172783, 2018
                                        4. Trop I: Is There a role for imaging surveillance after mastectomy and autologous breast reconstruction? Radiology. 181599, 2018
                                        5. Gigli S et al: Magnetic resonance imaging after breast oncoplastic surgery: an update. Breast Care (Basel). 12(4):260-265, 2017
                                        6. Lam DL et al: Imaging surveillance after primary breast cancer treatment. AJR Am J Roentgenol. 208(3):676-686, 2017
                                        7. Liu YQ et al: Ultrasound for postoperative surveillance after mastectomy in patients with breast cancer: a retrospective study. Medicine (Baltimore). 96(52):e9244, 2017
                                        8. Noor L et al: Imaging changes after breast reconstruction with fat grafting - retrospective study of 90 breast cancer. Pak J Med Sci. 32(1):8-12, 2016
                                        9. Pinell-White XA et al: Radiographic implications of fat grafting to the reconstructed breast. Breast J. 21(5):520-5, 2015
                                        10. Harris JR et al: Diseases of the Breast. 5th ed.: Lippincott Williams & Wilkins. 978-1451186277, 2014
                                        11. Margolis NE et al: Update on imaging of the postsurgical breast. Radiographics. 34(3):642-60, 2014
                                        12. Yoo H et al: Local recurrence of breast cancer in reconstructed breasts using TRAM flap after skin-sparing mastectomy: clinical and imaging features. Eur Radiol. 24(9):2220-6, 2014
                                        13. Atasoy MM et al: Sonography of fat necrosis of the breast: correlation with mammography and MR imaging. J Clin Ultrasound. 41(7):415-23, 2013
                                        14. Casey WJ 3rd et al: Etiology of breast masses after autologous breast reconstruction. Ann Surg Oncol. 20(2):607-14, 2013
                                        15. Hedegard W et al: Breast reconstruction with a deep inferior epigastric perforator flap: imaging appearances of the normal flap and common complications. AJR Am J Roentgenol. 200(1):W75-84, 2013
                                        16. Pinel-Giroux FM et al: Breast reconstruction: review of surgical methods and spectrum of imaging findings. Radiographics. 33(2):435-53, 2013
                                        17. Chansakul T et al: The postconservation breast: part 1, Expected imaging findings. AJR Am J Roentgenol. 2012 Feb;198(2):321-30
                                        18. Chansakul T et al: The postconservation breast: part 2, Imaging findings of tumor recurrence and other long-term sequelae. AJR Am J Roentgenol. 2012 Feb;198(2):331-43
                                        19. Doren EL et al: Sequelae of fat grafting postmastectomy: an algorithm for management of fat necrosis. Eplasty. 12:e53, 2012
                                        20. Drukteinis JS et al: MR imaging assessment of the breast after breast conservation therapy: distinguishing benign from malignant lesions. Radiographics. 32(1):219-34, 2012
                                        21. Edinger BW: Fat necrosis: BI-RADS 2 or 3? Radiographics. 32(5):1561-2; author reply 1562, 2012
                                        22. Karunanithy N et al: CT angiography of inferior epigastric and gluteal perforating arteries before free flap breast reconstruction. Radiographics. 31(5):1307-19, 2011
                                        23. Veber M et al: Radiographic findings after breast augmentation by autologous fat transfer. Plast Reconstr Surg. 127(3):1289-99, 2011
                                        24. Li J et al: Breast MRI after conservation therapy: usual findings in routine follow-up examinations. Am J Roentgenol. Sep;195(3):799-807, 2010
                                        25. Seo YY et al: FDG uptake in fat necrosis following transverse rectus abdominis myocutaneous (TRAM) flap reconstructed breasts: 3 cases. Clin Nucl Med. 35(4):283-5, 2010
                                        26. Neil-Dwyer JG et al: Magnetic resonance angiography in preoperative planning of deep inferior epigastric artery perforator flaps. J Plast Reconstr Aesthet Surg. 62(12):1661-5, 2009
                                        27. Taboada JL et al: The many faces of fat necrosis in the breast. AJR Am J Roentgenol. 2009;192(3):815-25
                                        28. Daly CP et al: Variable appearances of fat necrosis on breast MRI. AJR Am J Roentgenol. 191(5):1374-80, 2008
                                        29. Glynn C et al: Imaging breast augmentation and reconstruction. Br J Radiol. 81(967):587-95, 2008
                                        30. Lee JM et al: Detecting nonpalpable recurrent breast cancer: the role of routine mammographic screening of transverse rectus abdominis myocutaneous flap reconstructions. Radiology. 248(2):398-405, 2008
                                        31. Seely JM et al: Breast MRI in the evaluation of locally recurrent or new breast cancer in the postoperative patient: correlation of morphology and enhancement features with the BI-RADS category. Acta Radiol. 48(8):838-45, 2007
                                        32. Granzow JW et al: Breast reconstruction using perforator flaps. J Surg Oncol. 94(6):441-54, 2006
                                        33. Tan PH et al: Fat necrosis of the breast--a review. Breast. 15(3):313-8, 2006
                                        34. Bassett LW et al: Diagnosis of Diseases of the Breast. 2nd ed. Philadelphia: Saunders. 574-5, 2005
                                        35. Kang BJ et al: Breast MRI findings after modified radical mastectomy and transverse rectus abdominis myocutaneous flap in patients with breast cancer. J Magn Reson Imaging. 21(6):784-91, 2005
                                        36. Morris EA et al: Breast MR Diagnosis and Intervention. New York: Springer. 486-7, 2005
                                        37. Devon RK et al: Breast reconstruction with a transverse rectus abdominis myocutaneous flap: spectrum of normal and abnormal MR imaging findings. Radiographics. 24(5):1287-99, 2004
                                        38. Kim SM et al: Normal and abnormal US findings at the mastectomy site. Radiographics. 24(2):357-65, 2004
                                        39. Mehta VK et al: Postmastectomy radiation therapy after TRAM flap breast reconstruction. Breast J. 10(2):118-22, 2004
                                        40. Helvie MA et al: Mammographic screening of TRAM flap breast reconstructions for detection of nonpalpable recurrent cancer. Radiology. 224(1):211-6, 2002
                                        41. Whitehouse GH et al: MR imaging of the breast after surgery for breast cancer. Magn Reson Imaging Clin N Am. 2(4):591-603, 1994
                                        Related Anatomy
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                                        Related Differential Diagnoses
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                                        References
                                        Tables

                                        Tables

                                        KEY FACTS

                                        • Terminology

                                          • Imaging

                                            • Top Differential Diagnoses

                                              • Clinical Issues

                                                TERMINOLOGY

                                                • Abbreviations

                                                  • Transverse rectus abdominis myocutaneous (TRAM)
                                                  • Gluteal free flap, inferior gluteal artery perforator (IGAP)
                                                  • Superior gluteal artery perforator (SGAP) flap
                                                • Synonyms

                                                  • Neobreast
                                                  • Autologous reconstruction
                                                • Definitions

                                                  • Autologous breast tissue reconstruction
                                                    • Flaps may be used alone or in combination with breast implant (usually silicone)
                                                    • Perforator-only flaps
                                                      • Include overlying fat and skin
                                                      • No muscle loss: Minimal functional impairment, ↓ postoperative stay
                                                    • Myocutaneous flaps
                                                      • Include overlying fat and tissue as well as muscle pedicle
                                                      • Muscle loss, donor site weakening/hernias
                                                    • Recipient vessels: Internal mammary and thoracodorsal
                                                  • Myocutaneous and related flaps
                                                    • Delayed contralateral TRAM reconstruction not option: Bilateral TRAM reconstruction can only be performed at time of initial TRAM
                                                      • Requires sufficient abdominal fat to create suitable neobreast volume
                                                    • TRAM flaps
                                                      • Pedicled TRAM
                                                        • Portion of contralateral rectus abdominis muscle, overlying subcutaneous tissue, and skin
                                                        • Blood supply from superior epigastric vessels
                                                      • Free TRAM
                                                        • Created to improve blood supply; limit extensive dissection of full TRAM pedicle flap procedure
                                                    • Latissimus dorsi myocutaneous (LDM) flap
                                                      • Portion of ipsilateral latissimus dorsi muscle and overlying subcutaneous tissue
                                                      • May require implant + flap for adequate volume; AlloDerm sometimes used as sling for implant
                                                  • Perforator-only flap
                                                    • Superficial inferior epigastric perforator (SIEP)
                                                      • Skin/subcutaneous tissue only; perforating vessels from superficial inferior epigastric artery
                                                    • Deep inferior epigastric perforator (DIEP)
                                                      • Based on deep inferior epigastric vessels with advent of microvascular surgery
                                                    • Gluteal free flap
                                                      • Skin and subcutaneous tissue
                                                      • Technically most challenging
                                                      • Staged procedure if bilateral
                                                  • Autologous fat transfer/graft
                                                    • Used to smooth contour irregularities in reconstructed breast or lumpectomy site
                                                    • Liposuction fat, prepare cells, inject
                                                    • Substantial risk of fat necrosis

                                                IMAGING

                                                • General Features

                                                  • Imaging Recommendations

                                                    • Mammographic Findings

                                                      • Ultrasonographic Findings

                                                        • MR Findings

                                                          • CT Findings

                                                            DIFFERENTIAL DIAGNOSIS

                                                              PATHOLOGY

                                                              • General Features

                                                                • Gross Pathologic & Surgical Features

                                                                  • Microscopic Features

                                                                    CLINICAL ISSUES

                                                                    • Demographics

                                                                      • Natural History & Prognosis

                                                                        • Treatment

                                                                          DIAGNOSTIC CHECKLIST

                                                                          • Consider

                                                                            • Image Interpretation Pearls

                                                                              Selected References

                                                                              1. Bennett KG et al: Comparison of 2-year complication rates among common techniques for postmastectomy breast reconstruction. JAMA Surg. ePub, 2018
                                                                              2. Kwok AC et al: Immediate unilateral breast reconstruction using abdominally based flaps: analysis of 3,310 cases. J Reconstr Microsurg. 35(1):74-82, 2018
                                                                              3. Noroozian M et al: Use of screening mammography to detect occult malignancy in autologous breast reconstructions: a 15-year experience. Radiology. 172783, 2018
                                                                              4. Trop I: Is There a role for imaging surveillance after mastectomy and autologous breast reconstruction? Radiology. 181599, 2018
                                                                              5. Gigli S et al: Magnetic resonance imaging after breast oncoplastic surgery: an update. Breast Care (Basel). 12(4):260-265, 2017
                                                                              6. Lam DL et al: Imaging surveillance after primary breast cancer treatment. AJR Am J Roentgenol. 208(3):676-686, 2017
                                                                              7. Liu YQ et al: Ultrasound for postoperative surveillance after mastectomy in patients with breast cancer: a retrospective study. Medicine (Baltimore). 96(52):e9244, 2017
                                                                              8. Noor L et al: Imaging changes after breast reconstruction with fat grafting - retrospective study of 90 breast cancer. Pak J Med Sci. 32(1):8-12, 2016
                                                                              9. Pinell-White XA et al: Radiographic implications of fat grafting to the reconstructed breast. Breast J. 21(5):520-5, 2015
                                                                              10. Harris JR et al: Diseases of the Breast. 5th ed.: Lippincott Williams & Wilkins. 978-1451186277, 2014
                                                                              11. Margolis NE et al: Update on imaging of the postsurgical breast. Radiographics. 34(3):642-60, 2014
                                                                              12. Yoo H et al: Local recurrence of breast cancer in reconstructed breasts using TRAM flap after skin-sparing mastectomy: clinical and imaging features. Eur Radiol. 24(9):2220-6, 2014
                                                                              13. Atasoy MM et al: Sonography of fat necrosis of the breast: correlation with mammography and MR imaging. J Clin Ultrasound. 41(7):415-23, 2013
                                                                              14. Casey WJ 3rd et al: Etiology of breast masses after autologous breast reconstruction. Ann Surg Oncol. 20(2):607-14, 2013
                                                                              15. Hedegard W et al: Breast reconstruction with a deep inferior epigastric perforator flap: imaging appearances of the normal flap and common complications. AJR Am J Roentgenol. 200(1):W75-84, 2013
                                                                              16. Pinel-Giroux FM et al: Breast reconstruction: review of surgical methods and spectrum of imaging findings. Radiographics. 33(2):435-53, 2013
                                                                              17. Chansakul T et al: The postconservation breast: part 1, Expected imaging findings. AJR Am J Roentgenol. 2012 Feb;198(2):321-30
                                                                              18. Chansakul T et al: The postconservation breast: part 2, Imaging findings of tumor recurrence and other long-term sequelae. AJR Am J Roentgenol. 2012 Feb;198(2):331-43
                                                                              19. Doren EL et al: Sequelae of fat grafting postmastectomy: an algorithm for management of fat necrosis. Eplasty. 12:e53, 2012
                                                                              20. Drukteinis JS et al: MR imaging assessment of the breast after breast conservation therapy: distinguishing benign from malignant lesions. Radiographics. 32(1):219-34, 2012
                                                                              21. Edinger BW: Fat necrosis: BI-RADS 2 or 3? Radiographics. 32(5):1561-2; author reply 1562, 2012
                                                                              22. Karunanithy N et al: CT angiography of inferior epigastric and gluteal perforating arteries before free flap breast reconstruction. Radiographics. 31(5):1307-19, 2011
                                                                              23. Veber M et al: Radiographic findings after breast augmentation by autologous fat transfer. Plast Reconstr Surg. 127(3):1289-99, 2011
                                                                              24. Li J et al: Breast MRI after conservation therapy: usual findings in routine follow-up examinations. Am J Roentgenol. Sep;195(3):799-807, 2010
                                                                              25. Seo YY et al: FDG uptake in fat necrosis following transverse rectus abdominis myocutaneous (TRAM) flap reconstructed breasts: 3 cases. Clin Nucl Med. 35(4):283-5, 2010
                                                                              26. Neil-Dwyer JG et al: Magnetic resonance angiography in preoperative planning of deep inferior epigastric artery perforator flaps. J Plast Reconstr Aesthet Surg. 62(12):1661-5, 2009
                                                                              27. Taboada JL et al: The many faces of fat necrosis in the breast. AJR Am J Roentgenol. 2009;192(3):815-25
                                                                              28. Daly CP et al: Variable appearances of fat necrosis on breast MRI. AJR Am J Roentgenol. 191(5):1374-80, 2008
                                                                              29. Glynn C et al: Imaging breast augmentation and reconstruction. Br J Radiol. 81(967):587-95, 2008
                                                                              30. Lee JM et al: Detecting nonpalpable recurrent breast cancer: the role of routine mammographic screening of transverse rectus abdominis myocutaneous flap reconstructions. Radiology. 248(2):398-405, 2008
                                                                              31. Seely JM et al: Breast MRI in the evaluation of locally recurrent or new breast cancer in the postoperative patient: correlation of morphology and enhancement features with the BI-RADS category. Acta Radiol. 48(8):838-45, 2007
                                                                              32. Granzow JW et al: Breast reconstruction using perforator flaps. J Surg Oncol. 94(6):441-54, 2006
                                                                              33. Tan PH et al: Fat necrosis of the breast--a review. Breast. 15(3):313-8, 2006
                                                                              34. Bassett LW et al: Diagnosis of Diseases of the Breast. 2nd ed. Philadelphia: Saunders. 574-5, 2005
                                                                              35. Kang BJ et al: Breast MRI findings after modified radical mastectomy and transverse rectus abdominis myocutaneous flap in patients with breast cancer. J Magn Reson Imaging. 21(6):784-91, 2005
                                                                              36. Morris EA et al: Breast MR Diagnosis and Intervention. New York: Springer. 486-7, 2005
                                                                              37. Devon RK et al: Breast reconstruction with a transverse rectus abdominis myocutaneous flap: spectrum of normal and abnormal MR imaging findings. Radiographics. 24(5):1287-99, 2004
                                                                              38. Kim SM et al: Normal and abnormal US findings at the mastectomy site. Radiographics. 24(2):357-65, 2004
                                                                              39. Mehta VK et al: Postmastectomy radiation therapy after TRAM flap breast reconstruction. Breast J. 10(2):118-22, 2004
                                                                              40. Helvie MA et al: Mammographic screening of TRAM flap breast reconstructions for detection of nonpalpable recurrent cancer. Radiology. 224(1):211-6, 2002
                                                                              41. Whitehouse GH et al: MR imaging of the breast after surgery for breast cancer. Magn Reson Imaging Clin N Am. 2(4):591-603, 1994