What is the role of postsurgical breast imaging following breast reduction, augmentation, or reconstruction?

Updated: Dec 19, 2018
  • Author: Susan Ackerman, MD; Chief Editor: Eugene C Lin, MD  more...
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Answer

Answer

Mammographic appearances of postsurgical changes after breast reduction, breast reconstruction, and breast augmentation commonly are encountered. A variety of surgical techniques are used in breast reduction surgery. One of the most common is the keyhole incision technique. In this procedure, an incision is made around the areola and extended vertically in the 6-o'clock position to the inferior mammary fold. Typical mammographic findings may include alteration of the parenchymal architecture, cranial displacement of the nipple, patchy densities due to tissue removal and scarring, and the development of fat necrosis. Approximately 6 months after surgery, a new baseline mammogram should be obtained. Any new findings from the baseline examination, such as a developing density, mass, or calcifications, require a thorough evaluation, including possible tissue sampling.

Breast reconstruction may be performed after a mastectomy by means of reconstruction with autogenous tissue transfer and/or implants. The most common autogenous tissue transfer site is from the panniculus or from a free myocutaneous flap. The most frequent location of the donor tissue is from a flap harvested from the latissimus dorsi muscle or the transverse rectus abdominis muscle (TRAM) flap.

Mammographic imaging of the reconstructed breast may be requested for the evaluation of a clinically suspicious finding, such as a palpable mass. Standard mammographic views are performed with additional views (compression, magnification, tangential) and ultrasonography if needed. In general, most of the mammographic and clinical findings are related to the development of dystrophic changes within the donor tissue, such as oil cysts and fat necrosis. Typically, dystrophic changes can be recognized easily on the mammogram as benign. However, fat necrosis, dystrophic microcalcifications, and scarring also can mimic cancer, thus prompting biopsy.

(See the images below.)

Mediolateral oblique mammogram of the breast shows Mediolateral oblique mammogram of the breast shows a subpectoral (behind the muscle) silicone implant. Free silicone is noted outside the implant, within the soft tissue of the upper breast, consistent with implant rupture (see arrows).
Mediolateral oblique image of a transverse rectus Mediolateral oblique image of a transverse rectus abdominis muscle (TRAM) flap used to augment the breast volume instead of an implant. The native breast tissue is noted anterior to the TRAM flap and produces this unusual architecture.

The postsurgical mammographic observations identified after breast augmentation are related to the technical placement of the implant and the type of the implant. Standard and implant-displaced views are recommended. Assessment of the implants includes the location (subglandular or subpectoral), type (silicone, saline, mixed), contour (evaluation for possible rupture or weakening), and evaluation for possible complications (rupture, capsular formation). The evaluation of the native breast tissue may be obscured by the implant, thus hampering breast cancer detection. Rarely, breast tissue may be augmented by using native tissue harvested from the muscle or pedunculus. This produces an unusual mammographic appearance.

In a retrospective review of 64 patients who underwent partial mastectomy with immediate oncoplastic reduction mammoplasty reconstruction, although substantial tissue rearrangement was performed, there were low rates of abnormal postoperative mammograms and subsequent biopsies during the first 2 years following the procedure. [5]


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