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Mammography of Autologous Myocutaneous Flaps¹

¹ From Radiology Associates of Richmond, Richmond, Va (J.P.H.); the Department of Radiology, Georgetown University Medical Center, 3800 Reservoir Rd NW, Washington, DC 20007 (R.A.Z.); and the Department of Radiology, Medical College of Virginia/Virginia Commonwealth University, Richmond (E.S.d.P.). Recipient of a Certificate of Merit award for a scientific exhibit at the 1998 RSNA scientific assembly. Received March 2, 1999; revision requested April 7 and received July 22; accepted July 22. Address reprint requests to R.A.Z.

View larger version (22K): [in a new window]   Figure 1.   Classic TRAM flap. An elliptical island of skin and fat is elevated from the lower abdomen on a pedicle of the contralateral rectus abdominis muscle and rotated into the mastectomy defect. The origin of the C line is the umbilicus defect.

View larger version (20K): [in a new window]   Figure 2.   LD flap. An elliptical island of skin, fat, and a portion of the LD muscle is elevated and rotated anteriorly into the ipsilateral mastectomy site.

View larger version (10K): [in a new window]   Figure 3.   Inferior gluteus maximus free flap. An elliptical island of skin, fat, and a portion of the inferior gluteus maximus muscle is transposed to the mastectomy site.

View larger version (86K): [in a new window]   Figure 4a.   Normal mammographic appearance of a large TRAM flap. Craniocaudal (a) and mediolateral oblique (b) views of the reconstructed breast show primarily fatty tissue with a convex area of soft-tissue opacity in the central and posterior regions that corresponds to the pedicle of rectus abdominis muscle (arrows). Surgical clips are also seen.

View larger version (87K): [in a new window]   Figure 4b.   Normal mammographic appearance of a large TRAM flap. Craniocaudal (a) and mediolateral oblique (b) views of the reconstructed breast show primarily fatty tissue with a convex area of soft-tissue opacity in the central and posterior regions that corresponds to the pedicle of rectus abdominis muscle (arrows). Surgical clips are also seen.

View larger version (13K): [in a new window]   Figure 5.   Locations of potential radiopaque scars on mediolateral oblique (MLO) and craniocaudal (CC) mammograms (13). Line A corresponds to the superior edge of the flap and may be seen on both views. Line B corresponds to the lateral edge of the flap and is occasionally seen on the mediolateral oblique view. Line C corresponds to the sutured umbilicus defect and can be seen on both views. Line D corresponds to the inferior edge of the flap and is seen only on the mediolateral oblique view. Lines G and H correspond to the lateral (line G) and medial (line H) edges of the flap and are rarely seen on the craniocaudal view.

View larger version (118K): [in a new window]   Figure 6a.   Normal bilateral TRAM flaps. Craniocaudal (a) and mediolateral oblique (b) mammograms show the A line. The C line is seen on the left mediolateral oblique view (b).

View larger version (151K): [in a new window]   Figure 6b.   Normal bilateral TRAM flaps. Craniocaudal (a) and mediolateral oblique (b) mammograms show the A line. The C line is seen on the left mediolateral oblique view (b).

View larger version (39K): [in a new window]   Figures 7, 8.   (7) Normal right TRAM flap. Craniocaudal mammogram shows the A, G, and H lines. (8) Normal right TRAM flap. Mediolateral oblique mammogram shows the B and D lines. A large dystrophic calcification with adjacent suture calcifications is seen centrally (arrow).

View larger version (58K): [in a new window]   Figures 7, 8.   (7) Normal right TRAM flap. Craniocaudal mammogram shows the A, G, and H lines. (8) Normal right TRAM flap. Mediolateral oblique mammogram shows the B and D lines. A large dystrophic calcification with adjacent suture calcifications is seen centrally (arrow).

View larger version (71K): [in a new window]   Figure 9a.   Clinically silent recurrence of comedo-type ductal carcinoma in situ (DCIS) in a TRAM flap. (a) Original craniocaudal mammogram shows regional pleomorphic calcifications laterally in the right breast (arrowheads). Biopsy revealed DCIS of the comedo type. The patient underwent right mastectomy and reconstruction with a TRAM flap. (b) Follow-up mediolateral oblique mammogram obtained 2 years later shows clustered pleomorphic microcalcifications in the inferior aspect of the TRAM flap (arrow). An earlier mammogram of the TRAM flap was normal. Excisional biopsy revealed recurrent DCIS of the comedo type without evidence of invasion. The patient was treated with chest wall irradiation, and the TRAM flap was preserved.

View larger version (55K): [in a new window]   Figure 9b.   Clinically silent recurrence of comedo-type ductal carcinoma in situ (DCIS) in a TRAM flap. (a) Original craniocaudal mammogram shows regional pleomorphic calcifications laterally in the right breast (arrowheads). Biopsy revealed DCIS of the comedo type. The patient underwent right mastectomy and reconstruction with a TRAM flap. (b) Follow-up mediolateral oblique mammogram obtained 2 years later shows clustered pleomorphic microcalcifications in the inferior aspect of the TRAM flap (arrow). An earlier mammogram of the TRAM flap was normal. Excisional biopsy revealed recurrent DCIS of the comedo type without evidence of invasion. The patient was treated with chest wall irradiation, and the TRAM flap was preserved.

View larger version (59K): [in a new window]   Figure 10a.   Palpable early recurrence in a TRAM flap. (a) Original mediolateral oblique mammogram of the right breast shows a large, irregular soft-tissue mass with nipple retraction and tethering of the inferior pectoralis muscle (arrow). The patient underwent right mastectomy and immediate reconstruction with a TRAM flap. One year later, she presented with a palpable mass in the posterior central aspect of the reconstructed breast. (b) Craniocaudal mammogram of the TRAM flap shows an ill-defined, high-density mass posteriorly (arrows) with some tethering of the flap tissues. Biopsy revealed invasive ductal carcinoma.

View larger version (53K): [in a new window]   Figure 10b.   Palpable early recurrence in a TRAM flap. (a) Original mediolateral oblique mammogram of the right breast shows a large, irregular soft-tissue mass with nipple retraction and tethering of the inferior pectoralis muscle (arrow). The patient underwent right mastectomy and immediate reconstruction with a TRAM flap. One year later, she presented with a palpable mass in the posterior central aspect of the reconstructed breast. (b) Craniocaudal mammogram of the TRAM flap shows an ill-defined, high-density mass posteriorly (arrows) with some tethering of the flap tissues. Biopsy revealed invasive ductal carcinoma.

View larger version (40K): [in a new window]   Figures 11, 12.   (11) Fat necrosis in a TRAM flap. Mediolateral oblique mammogram shows an ill-defined area of soft-tissue density (arrows). Excisional biopsy revealed fat necrosis. (12) Progressive changes of fat necrosis in a TRAM flap. (a) Mediolateral oblique mammogram shows fat necrosis as an ill-defined area of soft-tissue density (arrows). (b) Follow-up mediolateral oblique mammogram shows an interval decrease in density and numerous calcifications adjacent to surgical clips.

View larger version (59K): [in a new window]   Figures 11, 12.   (11) Fat necrosis in a TRAM flap. Mediolateral oblique mammogram shows an ill-defined area of soft-tissue density (arrows). Excisional biopsy revealed fat necrosis. (12) Progressive changes of fat necrosis in a TRAM flap. (a) Mediolateral oblique mammogram shows fat necrosis as an ill-defined area of soft-tissue density (arrows). (b) Follow-up mediolateral oblique mammogram shows an interval decrease in density and numerous calcifications adjacent to surgical clips.

View larger version (27K): [in a new window]   Figures 11, 12.   (11) Fat necrosis in a TRAM flap. Mediolateral oblique mammogram shows an ill-defined area of soft-tissue density (arrows). Excisional biopsy revealed fat necrosis. (12) Progressive changes of fat necrosis in a TRAM flap. (a) Mediolateral oblique mammogram shows fat necrosis as an ill-defined area of soft-tissue density (arrows). (b) Follow-up mediolateral oblique mammogram shows an interval decrease in density and numerous calcifications adjacent to surgical clips.

View larger version (77K): [in a new window]   Figure 13.   Bilateral TRAM flap failure. Bilateral mediolateral oblique mammograms show extensive fat necrosis with large, calcified lipid cysts and pleomorphic and dystrophic calcifications.

View larger version (41K): [in a new window]   Figures 14, 15.   (14) Enlarged lymph node in a TRAM flap. Craniocaudal mammogram shows an 8-mm-diameter, well-circumscribed nodule in the lateral aspect of a right TRAM flap (arrow). This nodule corresponded to a palpable nodule detected at routine physical examination. Excisional biopsy revealed a benign lymph node. (15) Epidermal inclusion cyst in a TRAM flap. Mediolateral oblique mammogram shows an 8-mm-diameter, oval nodule in the inferior aspect of a right TRAM flap (arrows). Interval enlargement of the nodule prompted a stereotaxic core biopsy. Final histopathologic results showed an epidermal inclusion cyst.

View larger version (39K): [in a new window]   Figures 14, 15.   (14) Enlarged lymph node in a TRAM flap. Craniocaudal mammogram shows an 8-mm-diameter, well-circumscribed nodule in the lateral aspect of a right TRAM flap (arrow). This nodule corresponded to a palpable nodule detected at routine physical examination. Excisional biopsy revealed a benign lymph node. (15) Epidermal inclusion cyst in a TRAM flap. Mediolateral oblique mammogram shows an 8-mm-diameter, oval nodule in the inferior aspect of a right TRAM flap (arrows). Interval enlargement of the nodule prompted a stereotaxic core biopsy. Final histopathologic results showed an epidermal inclusion cyst.