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8. Blondeel PN, Demuynck M, Mete D, et al. Sensory nerve repair in perforator aps for autol-
ogous breast reconstruction: Sensational or senseless? Br J Plast Surg 52:37-44, 1999.
The spontaneous return of sensation in autologously reconstructed breasts, especially with the TRAM
ap, generated the belief that sensory reinnervation by nerve repair of the ap is super uous.This study
compares the sensation of the following nonreconstructed and reconstructed breasts: (1) nonoperated
breasts;(2) breasts reconstructed with DIEP/DIEAP aps and sensory nerve repair;(3) aps of pa-
tients reconstructed with DIEP/DIEAP aps without nerve repair;and (4) aps of patients recon-
structed with free TRAM aps without nerve repair. Statistically signi cant lower pressure thresholds
were found for DIEP/DIEAPP aps with nerve repair through Semmes-Weinstein testing. More seg-
ments of DIEP/DIEAP aps with nerve repair reacted to cold, warm, and vibratory stimuli than aps
without nerve repair. Delayed but satisfactory sensory-evoked potential responses were obtained for all
reconstructed breasts, but in 46% of TRAM aps no response could be registered compared with
23% and 0% for DIEP/DIEAP aps without and with nerve repair, respectively. Questionnaires
con rmed the objective data and showed return of erogenous sensation in 30% of patients who received
DIEP/DIEAP aps with nerve repair.The data recon rm the possibility of spontaneous return of
sensation in pedicled and/or free lower abdominal aps without nerve repair. Nevertheless, nerve re-
pair in free DIEP/DIEAP aps does restore sensation earlier postoperatively, increases the quality and
quantity of sensation in the ap, and has a higher chance of providing erogenous sensation.The ben-
e ts obtained outweigh the disadvantages of the increased operating time.
9. Futter CM, Weiler-Mithoff E, Hagen S, et al. Do preoperative abdominal exercises prevent
postoperative donor site complications for women undergoing DIEP ap breast reconstruc-
tion? A two-centre, prospective randomised controlled trial. Br J Plast Surg 56:674-683, 2003.
The DIEP/DIEAP ap is the current gold standard for breast reconstruction using abdominal tis-
sue. Unlike the TRAM ap, no rectus abdominis muscle is removed, but intramuscular scarring can
still cause postoperative complications. Strong abdominal muscles have been advocated as a prerequi-
site for this surgery, but without any evidence of the potential bene ts.This study investigated the ef-
fects of preoperative abdominal exercises on inpatient pain levels, length of hospital stay, postoperative
abdominal muscle strength, and function following a DIEP/DIEAP ap.
10. Koshima I, Moriguchi T, Soeda S, et al. Free thin paraumbilical perforator-based aps. Ann
Plast Surg 29:12-17, 1992.
A free paraumbilical perforator-based ap fed by a muscle perforator from the inferior deep epigastric
artery with no muscle was used in 13 patients. In seven patients, a free thin paraumbilical perforator
ap with a thin layer of fat was used to protect the subdermal plexus of the vessels.The dominant pedi-
cle perforator of this thin ap is usually located around the umbilicus, and a large ap can be obtained.
Its critical length-to-breadth ratio is thought to be 4:3.The advantages of this ap are a large vascu-
lar pedicle, rare postoperative abdominal herniation, little bulkiness of the ap, and a relatively large
skin territory.The disadvantages are technical dif culties of dissecting the perforator and anatomic
variation of the perforator location.The authors believe this ap largely overcomes the problems of the
conventional rectus abdominis musculocutaneous ap.
11. Taylor GI, Daniel RK.The anatomy of several free ap donor sites.Plast Reconstr Surg 56:243-
253, 1975.
The vascular anatomy of the supplying vessels to the iliofemoral, deltopectoral, axillary, and thoracoab-
dominal regions in fresh cadavers was investigated in detail. Other donor sites were also examined.
The anatomic relationship of the supplying vessels is discussed, and the design, conversion, and use
of these skin areas as donor sites for free ap transfer are detailed.The iliofemoral region is suggested
as the best donor site for most free ap procedures.
12. Carramenha e Costa MA, Carriquiry C,Vasconez LO, et al. An anatomic study of the venous
drainage of the transverse rectus abdominis musculocutaneous ap. Plast Reconstr Surg 79:208-
217, 1987.

13. Holmstrom H. The free abdominoplasty ap and its use in breast reconstruction. An experi-
mental study and clinical case report. Scand J Plast Reconstr Surg 13:423-427, 1979.
In search of a free microvascular ap that would give abundant reconstructive material as well as a sat-
isfactory donor site, the free abdominoplasty ap was developed.The ap is designed on the area be-
tween the umbilicus, the pubic region, and the anterior superior iliac spines, and is based on the infe-
rior epigastric vessels on one side only. In eight regular abdominoplasty procedures, elevation of this ap
and keeping the blood ow intact through isolated vessels did not jeopardize viability of the ap.An-
giography of the specimens showed good perfusion.The free abdominoplasty ap has been used for
breast reconstruction in two cases of radical mastectomy.The rst failed because of venous thrombosis.
Three veins were anastomosed in the second case:two venae comitantes to the inferior epigastric vein
and the contralateral super cial epigastric vein.The result was favorable.
14. Pennington DG, Nettle WJ, Lam P, et al. Microvascular augmentation of the blood supply of
the contralateral side of the free transverse rectus abdominis musculocutaneous ap. Ann Plast
Surg 31:123-126; discussion 126-127, 1993.
15. Arnez ZM, Smith RW, Eder E, et al. Breast reconstruction by the free lower transverse rectus
abdominis musculocutaneous ap. Br J Plast Surg 41:500, 1988.
16. Grotting JC, Urist MM, Maddox WA, et al. Conventional TRAM ap versus free microsurgi-
cal TRAM ap for immediate breast reconstruction. Plast Reconstr Surg 83:828, 1989.
17. Nahai F, Bostwick J III. Microsurgical techniques. In Bostwick J III. Plastic and Reconstructive
Breast Surgery. St Louis: Quality Medical Publishing, 1991.
18. Friedman RJ, Argenta LC,Anderson R. Deep inferior epigastric free ap for breast reconstruc-
tion after radical mastectomy. Plast Reconstr Surg 76:455-460, 1985.
19. Blondeel PN, Arnstein M,Verstraete K, et al.Venous congestion and blood ow in free trans-
verse rectus abdominis myocutaneous and deep inferior epigastric perforator aps. Plast Recon-
str Surg 106:1295-1299, 2000.
A series of 240 DIEP/DIEAP aps and 271 free TRAM aps from two institutions was reviewed
to determine the incidence of diffuse venous insuf ciency that threatened ap survival and required a
microvascular anastomosis to drain the super cial inferior epigastric vein.This problem occurred in ve
DIEP/DIEAP aps and did not occur in any of the free TRAM aps. In each case a super cial in-
ferior epigastric vein was present that was larger than usual.Therefore it is suggested that if an
unusually large super cial inferior epigastric vein is noted when a DIEP/DIEAP ap is elevated, the
vein should be preserved for possible use in ap salvage.
20. Grotting JC. Breast reconstruction with free tissue transfer. In Cohen M, ed. Mastery of Plas-
tic and Reconstructive Surgery. Boston: Little Brown, 1994.
21. Elliott LF. The lateral transverse thigh free ap for autologous breast reconstruction. Perspect
Plast Surg 3:80-87, 1989.
22. Fujino T, Harashina T, Aoyagi F. Reconstruction for aplasia of the breast and pectoral region by
microvascular transfer of a free ap from the buttock. Plast Reconstr Surg 56:178-181, 1975.
23. Fujino T, Harashina T, Enomoto K. Primary breast reconstruction after a standard radical mas-
tectomy by a free ap transfer. Plast Reconstr Surg 58:371-374, 1976.
24. Shaw WW. Breast reconstruction by superior gluteal microvascular free aps without silicone
implants. Plast Reconstr Surg 72:490-501, 1983.
25. Harashina T, Imai T, Nakajima H, et al. Breast reconstruction with microsurgical free compos-
ite tissue transplantation. Br J Plast Surg 33:30-37, 1980.
26. Le-Quang C.Two new free aps developed from aesthetic surgery. II.The inferior gluteal ap.
Aesthetic Plast Surg 4:159-168, 1980.
27. Paletta CE, Bostwick J III, Nahai F.The inferior gluteal free ap in breast reconstruction. Plast
Reconstr Surg 84:875-883, 1989.
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Reoperation Following Free Flap Breast Reconstruction

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PART IV
R EOPERATIVE SURGERY OF THE BREAST AND CHEST WALL
28. Jones GT, Cramer A, Cohen LB, et al.The inferior gluteal-posterior thigh ap (the trefoil ap)
for autologous reconstruction of the breast. Presented at the Annual Meeting of the American
Society for Reconstructive Microsurgery, Kansas City, MO, Sept 1993.
29. Volpe AG, Rothkopf DM,Walton RL.The versatile super cial inferior epigastric ap for breast
reconstruction. Ann Plast Surg 32:113-117, 1994.
30. Grotting JC.The free abdominoplasty ap for immediate breast reconstruction. Ann Plast Surg
27:351-354, 1991.
31. Allen RJ,Treece P. Deep inferior epigastric perforator ap for breast reconstruction. Ann Plast
Surg 32:32-38, 1994.
The ideal materials for reconstructing a breast are fat and skin. Most current methods of autogenous
reconstruction use myocutaneous aps.The authors investigated the feasibility of transfering skin and
fat from the lower abdomen without muscle sacri ce.The ap is based on one, two, or three perfora-
tors of the deep inferior epigastric vessels.The study demonstrates this original technique both exper-
imentally and clinically. Fifteen breasts have been successfully reconstructed with this technique, which
has all the advantages of the free TRAM ap with decreased possibility of ventral hernia or muscle
weakness.
32. Koshima I, Soeda S. Inferior epigastric artery skin aps without rectus abdominis muscle. Br J
Plast Surg 42:645-648, 1989.
The rectus abdominis musculocutaneous ap has many advantages, but its disadvantages include the
possibility of abdominal herniation and, in certain situations, its bulk.To overcome these problems an
inferior epigastric artery skin ap without rectus abdominis muscle, pedicled on the muscle perforators
and the proximal inferior deep epigastric artery, was used in two patients. A large ap without mus-
cle can survive on a single muscle perforator.
33. Boyd JB,Taylor GI, Corlett R, et al.The vascular territories of the superior epigastric and the
deep inferior epigastric systems. Plast Reconstr Surg 73:1-16, 1984.
The vascular territories of the superior and deep inferior epigastric arteries were investigated by dye in-
jection, dissection, and barium radiographic studies. It was established that the deep inferior epigastric
artery is more signi cant than the superior epigastric artery in supplying the skin of the anterior ab-
dominal wall. Segmental branches of the deep epigastric system pass upward and outward into the
neurovascular plane of the lateral abdominal wall, where they anastomose with the terminal branches
of the lower six intercostal arteries and the ascending branch of the deep circum ex iliac artery.The
anastomoses consist of multiple narrow “choke”vessels. Similar connections are seen between the su-
perior and deep inferior epigastric arteries within the rectus abdominis muscle, well above the level of
the umbilicus. Many perforating arteries emerge through the anterior rectus sheath, but the highest con-
centration of major perforators is in the paraumbilical area.These vessels are terminal branches of the
deep inferior epigastric artery.They feed into a subcutaneous vascular network that radiates from the
umbilicus like the spokes of a wheel. Once again, choke connections exist with adjacent territories:in-
feriorly with the super cial inferior epigastric artery, inferolaterally with the super cial circum ex il-
iac artery, and superiorly with the super cial superior epigastric artery. However, the dominant con-
nections are superolaterally with the lateral cutaneous branches of the intercostal arteries. For breast
reconstruction, it would appear that prior ligation of the deep inferior epigastric artery would be ad-
vantageous when elevating the lower abdominal skin on a superiorly based rectus abdominis muscu-
locutaneous ap.The vascularity of this ap would be further increased by positioning some part of
the skin paddle over the dense pack of large paraumbilical perforators. Based on these anatomic stud-
ies the relative merits of the superior and deep inferior epigastric arteries with respect to local and
distant tissue transfer using various elements of the abdominal wall are discussed in detail.
34. Kikuchi N, Murakami G, Kashiwa H, et al. Morphometrical study of the arterial perforators of
the deep inferior epigastric perforator ap. Surg Radiol Anat 23:375-381, 2001.
35. Felmerer G, Muehlberger T, Berens von Rautenfeld D, et al.The lymphatic system of the deep
inferior epigastric artery perforator ap:An anatomical study. Br J Plast Surg 55:335-339, 2002.
36. Blondeel PN, Morris SF, Hallock GG, Neligan PC, eds. Perforator Flaps:Anatomy,Technique,
& Clinical Applications. St Louis: Quality Medical Publishing, 2006.

37. Sera n D, Georgiade NG. Transfer of free aps to provide well-vascularized, thick cover for
breast reconstructions after radical mastectomy. Plast Reconstr Surg 62:527-536, 1978.
38. Sera n D,Voci V, Georgiade N. Microsurgical composite tissue transplantation:Indications and
technical considerations in breast reconstruction following mastectomy. Plast Reconstr Surg
70:24-36, 1982.
39. Elliott LF, Hartrampf CR Jr.The “Ruben” ap for breast reconstruction. Presented at the An-
nual Meeting of the Southeastern Society of Plastic and Reconstructive Surgeons, Amelia Is-
land, FL, June 1993.
40. Hartrampf CR Jr, Noel RT, Drazan L, et al. Rubens’s fat pad for breast reconstruction: A per-
iliac soft-tissue free ap. Plast Reconstr Surg 93:402-407, 1994.
41. Yousif JN, Kolachalam RB, Matloub HS, et al.The axial orientation of perforators in the up-
per medial thigh: Anatomic basis of the transverse upper gracilis musculocutaneous ap. Pre-
sented at the Thirty-Fourth Annual Meeting of the Plastic Surgery Research Council, Atlanta,
April 1989.
42. Vila R, Guinot A. Post-mastectomy breast reconstruction in an irradiated eld using a con-
tralateral latissimus dorsi free ap. Br J Plast Surg 35:371-373, 1982.
43. Le-Quang C. Microvascular tissue transfer in plastic surgery. In Lie TS, ed. Microsurgery:Pro-
ceedings of the International Conference of the International Microscopical Society. Amster-
dam: Excerpta Medica, 1979.
44. Le-Quang C.Two new free aps developed from aesthetic surgery.I.The lateral mammary ap.
Aesthetic Plast Surg 4:147-157, 1980.
45. Schusterman M, Kroll SS,Weldon ME. Immediate breast reconstruction:Why the free TRAM
over the conventional TRAM ap? Plast Reconstr Surg 90:255-262, 1992.
46. Anton MA, Eskenazi LB, Hartrampf CR Jr. Nipple reconstruction with local aps: Star and
wrap aps. Perspect Plast Surg 5:67-78, 1991.
47. McCraw JB. Fish-tail ap [poster session]. Presented at the Annual Meeting of the American
Society of Plastic and Reconstructive Surgeons,Washington, DC, Sept 1992.
48. Wong RKM, Feldman S, Banducci DR. A modi cation of the Anton-Hartrampf star ap us-
ing pre-reconstruction tattooing. Perspect Plast Surg 7:137-140, 1993.
49. lllouz YG. How to create a new umbilicus. Aesthetic Surg Newsletter, Summer 1992, p 16.
50. Core GB, Grotting JC. Peripheral nerve injury in the free TRAM procedure. Perspect Plast
Surg 7:49-57, 1993.
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1. A failing free ap:
a. Represents a plastic surgery emergency
b. Indicates the need for a return to the operating room
c. Is frequently salvageable
d. May require vein grafts
e. All of the above
2. The simplest bedside monitoring device for vessel ow in pre ap breast recon-
struction is a:
a. Duplex scanner
b. Implantable Doppler
c. Hand-held Doppler
d. Intravenous uorescein
e. Temperature probe
3. A rm mass is noted in the superior pole of a free TRAM ap 6 weeks postop-
eratively. Appropriate management would be:
a. Exploration and biopsy
b. Radiotherapy consultation for recurrent tumor
c. Continued observation for probable fat necrosis
d. Needle localization biopsy
e. Placement of drain
4. Small contour de cits following free ap breast reconstruction can be managed
by:
a. Autologous fat grafting
b. Dermal fat grafts
c. Local adipose transposition ap
d. Small subpectoral implant
e. All of the above
5. Nipple reconstruction following free ap breast reconstruction:
a. Should usually be done at the time of ap transfer
b. Will frequently fail if done at the time of free ap transfer
c. Might end up asymmetrical with the opposite side if done at the time of
free ap transfer
d. Should always be accomplished at the nal stage of reconstruction
e. Is best accomplished with labia majora
R EVIEW QUESTIONS

1481
The desire to beautify breasts goes back many millennia. For the most part, early
efforts were primarily decorative. It is only in the last century that the ability to de-
liberately enhance the size and contour of the breasts has become a reality. Today
more than 2 million women in the United States alone have augmented breasts. In
2005, nearly 300,000 women in the United States underwent surgery to enlarge
their breasts.1
Imaging Considerations in
Plastic Surgery of the Breast
Eva Rubin and Stamatia V. Destounis
C ha pter 3 8
Reoperative Problems
Detection of silicone leakage
Dif culty differentiating abnormalities
Veri cation of implant integrity
Recognition of postsurgical
Breast tissue partially obscured
parenchymal alterations after
by implant
breast surgery
The scientist must consider the possibility, which usually amounts
to a certainty, that his work will be superseded by others within
a relatively short time, that his methods will be improved upon,
and that the new results will be more accurate.
Wilhelm Roentgen

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PART IV
R EOPERATIVE SURGERY OF THE BREAST AND CHEST WALL
Reduction mammaplasty, which in countries such as Brazil is an even more popu-
lar procedure than augmentation, is also being performed with increasing frequency
in the United States. It is said to be the operation with the highest satisfaction rate
among cosmetic surgery procedures. A total of 114,250 reduction mammaplasties
were performed in women in 2005—a 35% increase over a 5-year period.With the
epidemic of obesity that has overtaken the United States in recent years, the num-
ber of reduction procedures is almost certain to rise.The number of mastopexies is
also rising with 92,740 procedures performed in 2005.
Although most breast augmentation and reduction procedures today are primarily
done for purely cosmetic reasons, approximately 20% of such procedures are under-
taken to correct developmental, posttraumatic, postsurgical, or posttreatment defor-
mities of the breast. Specialized procedures have been created to deal with all of
these problems, and the imaging considerations for all of these as well as the more
routine augmentation and reduction procedures will be discussed.The occurrence
and detection of breast cancer in cosmetically altered breasts will be reviewed in a
separate section.
This 34-year-old woman with Poland’s syndrome had breast reconstruction with a
saline implant in her left breast.The patient’s right breast was also reduced.

THE AUGMENTED BREAST
In 1962 Dow Corning developed the rst silicone gel– lled breast implant.Thirty
years later, the FDA restricted the use of silicone gel implants for women seeking
aesthetic breast surgery.The history of devices for breast augmentation has been an
interesting series of ups and downs, as much related to science as to politics.
Before the development of breast-speci c implant devices, insertion of foreign bod-
ies, ranging from balls crafted of glass or ivory to ping-pong balls, had been at-
tempted.2 Injection of foreign substances into breast tissue for augmentation pur-
poses was also used, the first recorded instance being the use of paraffin in the
early1900s.3
During World War II, silicone in liquid form was found to be an excellent insula-
tor in transformers. Japanese prostitutes attempting to attract American servicemen
around the time of World War II developed methods of direct injection using sili-
cone, much of it obtained from pilfered transformer uid from the docks of the
United States Navy. Paraf n and silicone were both used for breast augmentation
and were popular even in the United States, especially among Las Vegas showgirls.
It was estimated that at least 40,000 women in Las Vegas had undergone these pro-
cedures by 1976, when the procedure was made a felony under Nevada state law.4
In 1965 silicone was classi ed as a drug under the jurisdiction of the FDA and reg-
ulation began, effectively discontinuing the practice of augmentation by direct in-
jection in the United States. However, direct injection continues to be used abroad,
particularly in the Far East, where it provides a relatively simple and affordable al-
ternative to implant procedures.
DIRECT INJECTION: PARAFFIN AND SILICONE
The early appearance of the breast after paraf n or silicone injection simulates that
of extensive brocystic change. Mammograms show multiple well-de ned non-
calci ed round nodules. Ultrasound imaging shows multiple cystic masses. These
may be located within or behind the parenchyma as well as in the axilla and pec-
toralis. MRI reveals T1 hypointense and T2 hyperintense nonenhancing masses.5
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Chapter 38
Imaging Considerations in Plastic Surgery of the Breast

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PART IV
R EOPERATIVE SURGERY OF THE BREAST AND CHEST WALL
This patient had a history of free silicone injections in the late 1970s. Her 2006
mammography lms show numerous dense nodules (silicone granulomas) and sub-
sequent placement of subglandular saline implants.
Mammograms before 1987
2006 mammograms

Above left, an axial MRI using a silicone-
speci c sequence shows hyperintense masses of
injected silicone.Above right,ultrasound shows
a cystic mass surrounded by a snowstorm effect
produced by intramammary silicone. Bottom
right, an axial silicone suppressed sequence
shows normal breast tissue.
Later, the injections result in the development
of paraf nomas or siliconomas,which can sim-
ulate breast cancers.The typical mammographic
appearance of paraffinomas is that of dense
streaky opacities in the midbreast retroglandular
region accompanied by areas of bizarre archi-
tectural distortion.The whole breast is involved with multiple dense nodules (paraf-
nomas).The paraf nomas may calcify;rounded or ring-shaped occulent or amorph-
ous patterns of calci cation have been described.6 Migration of paraf n along tissue
planes may result in development of large calci c masses in the chest or abdominal
wall.These masses may also be found in the axilla and anterior mediastinum.
Ultrasound in the late stages reveals extensive shadowing resulting from the brotic
changes. Khong et al7 classi ed magnetic resonance ndings in paraf nomas into
two components described as the main component and the round component.The
main component is a plaquelike in ltrative process related to brosis. It is isointense
to broglandular tissue on T1-weighted sequences and hypointense to fat on T2-
weighted sequences.The round paraf n globs have low signal intensity on both T1-
and T2-weighted sequences that becomes even lower on fat-suppressed sequences,
sometimes even hypointense relative to subcutaneous fat. Magnetic susceptibility
artifacts may be seen around the nodules, presumably related to calci cations.
In ammatory reactions, tissue necrosis, and draining sinus tracts may result from
paraf n injections. Migration of the oily material into the bloodstream can also re-
sult in more serious complications such as pulmonary and cerebral embolism.
The effects of direct silicone injection into the breast are similar to those of paraf-
n and, to some extent, those that can be anticipated from leakage of silicone im-
plants. Granulomatous in ammatory changes, brosis, and calci cation are com-
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Chapter 38
Imaging Considerations in Plastic Surgery of the Breast
Subtraction

1486
PART IV
R EOPERATIVE SURGERY OF THE BREAST AND CHEST WALL
mon sequelae. Silicone in direct contact with tissue is picked up by macrophages
and when injected in high doses accumulates in multiple organs, including the
lymph nodes, liver, spleen, adrenals, kidneys, pancreas, and ovaries, among others.8
Regional lymph nodes from patients with breast implants often have histologic ev-
idence of silicone migration. Characteristic histologic findings include foamy
macrophages and retractile droplets of clear material.9 Similar to paraf n, silicone
may result in tissue necrosis and formation of sinus tracts as well as (rarely) em-
bolization that may be lethal.10
AUGMENTATION W ITH FAT
In 1895 Czerny transplanted a lipoma from the back of an actress to ll in a breast
defect caused by removal of a broadenoma.11 This was the rst recorded instance
of fat being used to augment or reconstruct breast tissue. Unfortunately, the long-
term effects of this procedure were not recorded.
Although fat is certainly an attractive source for volume enhancement, the use of
devascularized fatty tissue has been thought to in fat necrosis that can unfavorably
alter both the contour and palpable characteristics of breast tissue. Therefore the
practice has been discouraged, except in small amounts in reconstructive patients.
Recently, however, methods of lipoinjection for breast augmentation or for cor-
rection of deformities following surgery, particularly lumpectomy, have regained
favor.12 The injection of fat as small particles (3 mm or less) appears to be associated
with fewer side effects, such as brosis and calci cation, and better retention of the
transplanted adipose tissue.13 Complications resulting in the need for lumpectomy14
and even subcutaneous mastectomy15 have been reported. Others have reported
development of extensive calci cations suf cient to interfere with mammographic
interpretation.16
BREAST IMPLANTS
The rst breast-speci c implants were Ivalon sponge implants developed in 1948.
These were followed by the silicone gel– lled implants developed by Cronin and
Gerow for Dow Corning in 1962 and 3 years later by saline- lled implants.Present-
day implants may be lled with saline solution, silicone, or a combination of the
two with at least 14 major implant types classi ed.17 Saline- lled implants have the
advantage of being radiolucent but tend to de ate at a higher rate than silicone
gel– lled implants. The spontaneous de ation rate of saline- lled implants is ap-
proximately 1% per year. Fat- lled (peanut and soy oil) implants are even more
radiolucent than saline-filled implants and were briefly available in the United
States. Approximately 5000 soy- lled implants were inserted in Europe and 50 in
the United States. They were removed from the market in 1999 because of prob-
lems with leakage, in ammation, and rancidity.18
Implants may contain from one to three lumens. In some implants one lumen is
contained within another (such as silicone within saline or vice versa) or implants
may be stacked with one behind the other.

Implants also vary in the composition of the outer envelope. Most are silicone elas-
tomer shells, but textured surfaces and polyurethane-coated surfaces have also been
used to lessen the incidence of capsular contracture.Textured implants may be rec-
ognizable on mammography because of ne undulations, serrations, or fuzziness
of the implant contour.
Both the composition (relative radiolucency) and the positioning of implants within
the breast affect the diagnostic quality of imaging.Implants may be placed in contact
with the breast tissue (subglandular) or behind the pectoral muscle (subpectoral).
Subglandular placement is easier and produces a more natural contour and more vo-
luminous augmentation than subpectoral implantation.In addition,subglandular im-
plants are not subject to displacement caused by contraction of the pectoralis.Subpec-
toral implants, however, allow imaging of a greater volume of breast tissue, and have
signi cantly lower rates of capsular contracture and loss of nipple sensation.19
Breast implants, similar to other implanted devices, induce a tissue reaction around
themselves consisting of a brous capsule.20 Capsular contracture may occur caus-
ing undesirable rmness of the implant. Calci cations of the brous capsule are
common and may be seen on mammograms. Pain, hematoma, infection, and rarely
allergy may also occur in response to the placement of a breast prosthesis.
1487
Chapter 38
Imaging Considerations in Plastic Surgery of the Breast
This 77-year-old patient is shown 30 years after bilateral silicone breast augmenta-
tion. Note the bilateral contracture manifested as abnormal rounding of the implant
contours and calci cation of the brous capsule.

1488
PART IV
R EOPERATIVE SURGERY OF THE BREAST AND CHEST WALL
The presence of an implant within the breast obscures some breast tissue, and the
rigidity of an implant also limits the amount of compression that can be applied to
the breast tissue. In addition, the implant itself compresses the native breast tissue re-
sulting in increased density of the breast. All of these factors unfavorably affect
mammographic image quality.
The extent to which image quality is adversely affected by implants is not precisely
known, and there are no studies that precisely de ne diagnostic accuracy of mam-
mography in women with implants to that of women with small, dense breasts, as
is the case in the typical implant candidate.
Nonetheless, methods to rectify or at least ameliorate the suboptimal imaging pro-
duced by the presence of implants have been sought. These include modi ed po-
sitioning for mammography and the use of adjunctive imaging methods such as
ultrasound, CT, and MRI.
This is an ultrasound image of a normal saline breast implant in a 50-year-old pa-
tient 6 months after lumpectomy with reconstruction. Note the uninterrupted out-
line of the surface of the implant.
Mammography in women with implants is currently performed with a technique
rst described by Eklund et al20 in 1988.The implant is displaced posteriorly against
the chest wall and the breast is pulled forward over the implant. The compression
plate is then lowered, in effect treating the implant as if it were the chest wall; the
area under the compression plate is mainly breast tissue with little or no implant
displayed on the image.The displacement technique results in visualization of ap-
proximately 10% more tissue in women with subglandular implants and 20% more
in women with subpectoral implants.21

Mammograms of women with implants consist of the standard four views (medio-
lateral oblique and craniocaudal views of each breast with the implant displayed
on the lm) and the four modi ed or pushback views (mediolateral and craniocau-
dal views with the implant off the lm). In cases with rm encapsulation, a supple-
mental pushback true lateral view may allow visualization of more tissue.
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A normal saline breast implant is shown in bilateral mediolateral oblique (MLO),
craniocaudal (CC), and MLO and CC implant-displaced views.
Displacement of implant
Standard mammograms

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Views that include the implant are necessary to depict abnormalities of the im-
plant itself, whereas the pushback views optimize the evaluation of potential breast
lesions. Implant abnormalities include displacement, contour deformities, encap-
sulation, puckers, protrusions, diverticula, and collapse. For women with possible
breast abnormalities noted on the standard pushback projections or on palpation,
additional views, such as spot compression and magni cation, can be performed
using the pushback technique. In addition, percutaneous biopsies with stereotactic
techniques and needle localization procedures are typically performed in pushback
projection.
Implant Rupture
Although alterations in position, contour, and rmness affect the cosmetic quality
of breast prostheses, the issue of greatest concern is rupture, which not only affects
cosmetic quality but can also have adverse health consequences when the implant
is lled with silicone.
The silicone elastomer shell of silicone implants is permeable to the silicone gel
contained within.The transudation of microscopic amounts of silicone gel through
an intact silicone envelope is called gel bleed.22 It likely occurs normally with all
implants.When greater, although still microscopic, amounts of silicone are extruded
through detectable small holes in the implant envelope result in a thin (usually less
than 0.5 mm) coating of gel on the implant surface;the phenomenon is designated
as a gel leak. When a major tear of the silicone envelope results in extrusion of
macroscopic amounts of silicone gel, rupture is said to have occurred. Ruptures
may be contained by the brous capsule that has formed around the implant (in-
tracapsular) or may be in direct contact with mammary or extramammary tissue
(extracapsular).

This 58-year-old patient with silicone implants was evaluated for contour defor-
mity of the right breast. Intracapsular implant rupture was con rmed on MRI and
is manifested as the so-called linguine sign.
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This 57-year-old patient presented for evaluation of the left implant. Mammogra-
phy, ultrasound, and MRI examinations were performed and con rmed intracap-
sular and extracapsular left implant rupture.
Ruptures may occur because of puncture during insertion, manufacturing defects,
spontaneous failure, and trauma. Closed capsulotomy, a forceful manual procedure
performed by plastic surgeons (or patients) to attempt to relieve capsular contracture,
was in the past the major cause of implant ruptures.23 Because of this, this procedure
has for the most part been abandoned. Trauma caused by motor vehicle accidents,
falls,and medical procedures along with spontaneous failures are now responsible for
the majority of implant failures.24 Depressurization during airplane ights may also
result in implant rupture.25 There are increasingly more reports (and litigation) re-
lated to implant rupture during mammography.26 The compressive force applied
during mammography is insuf cient to rupture an intact implant. However, with
time, most implants are not intact. In fact, the major predisposing factor for implant

rupture is the age of the implant. By 10 years, it is calculated that more than 50% of
implant shells are no longer intact. In a review by Robinson et al,27 it was found that
nearly two thirds of implants in place from 1 to 25 years were leaking or had rup-
tured. Studies have shown an inverse relationship between the pressure resistance or
integrity of implants and the duration of implantation.28
Intracapsular ruptures of silicone implants are not a major cause for concern be-
cause the silicone is held in place by the surrounding brous capsule. Intracapsular
ruptures account for 77% to 89% of implant failures.21 The remaining 11% to 23%
of implant ruptures are extracapsular and in these ruptures, silicone may migrate
within breast tissue and rarely through the ducts, causing silicone nipple discharge.29
From the breast it may be picked up by axillary nodes and may then travel to dis-
tant sites causing formation of granulomas. Migrated silicone has been detected in
pleura, lungs, liver, bone, extremities, abdominal wall, and groin.4 Aside from pain,
lumps, swelling, and unsightly skin lesions, migration of silicone around vital struc-
tures such as the nerves of the brachial plexus may cause truly signi cant symp-
toms.30 Extracapsular rupture is considered by most an indication for implant re-
moval; the management of intracapsular ruptures is somewhat more controversial.
Detection of Implant Rupture
Sequential mammograms showing loss of volume or change in contour of implants
over time may be presumptive evidence of implant failure. Saline implants often
have visible folds on mammography that increase in prominence over time. Be-
cause saline leaks are readily absorbed by the body without ill effects, such rup-
tures are not usually cause for concern unless they produce signi cant asymme-
tries or volume reduction.
Alterations in implant contour such as focal bulges, herniations, and diverticula are
the result of weakening of the implant envelope.These occur in up to 20% of pa-
tients and are readily detectable on the nondisplaced mammographic views.
Periprosthetic calci cation is present in at least one fourth of women with implants
and is also readily visible on mammography, particularly with digital techniques.
If calci cation adjacent to the implant is extensive and the implant is in subglandu-
lar position, abnormalities arising close to the implant may be obscured. In most
cases, pericapsular calci cation is readily recognized as benign on the x-ray mam-
mogram.Thin plaques of calci cation or bulky curvilinear calci cations as well as
the distinctive coarse calcifications of fat necrosis are most common. However,
when the calci cations are ne and localized as may occur in the early stages of fat
necrosis, distinction from malignant calci cation may not be possible and biopsy
will be required.
Occasionally, deformities of contour of the implant may present as palpable breast
masses. This is usually readily diagnosed on the standard mammographic projec-
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tions. Ultrasonography may also help to verify that a palpable abnormality repre-
sents the implant itself.31 One must be cautious, however, not to mistake infoldings
and wrinkles of the silicone envelope seen on ultrasound for tears.32
Intracapsular rupture is not detectable by mammography. Extracapsular rupture is
usually readily identi ed on x-ray mammograms obtained by means of the implant
displacement technique. Globules of free silicone may be seen within breast tissue.
If present for prolonged periods, the extruded silicone globs may calcify as in cases
of direct silicone injection. In addition, silicone may be visible in axillary nodes or
migrating along tissue planes in the axilla.
Mediolateral oblique and craniocaudal views before, and 20-degree mediolateral
oblique, and 90-degree spot magni cation views after explantation of a silicone
implant in a 47-year-old patient are presented. A mass of residual silicone is pres-
ent on the views obtained after implant removal.
Intracapsular rupture may be seen on ultrasound, but only in approximately 50% of
cases.33 Instead of the two parallel echogenic lines that characterize the appearance
of an intact implant envelope, multiple discontinuous parallel lines may be visible
within the implant (stepladder sign).34,35 Unfortunately, infoldings of the implant
envelope may cause a similar appearance, making ultrasound imaging much less re-
liable than MRI in the evaluation of intracapsular rupture. Similarly, internal
echogenicity within an implant may indicate intracapsular rupture but may also be
caused by reverberation artifacts or by admixture of uid and silicone gel in cases
in which saline has been injected into an implant to achieve more volume at the
time of implantation.
Intramammary silicone produces a distinctive snowstorm appearance on ultrasound.
This is manifest as a uniform pattern of sharply delineated ne echoes that obscure
posterior detail. Extruded silicone may also be visible as a hypoechoic mass adjacent
to the implant surface and in these cases may be indistinguishable from neoplasm.36

This 64-year-old patient presented for evaluation of right breast implant. An ultra-
sound image of this patient is shown after mastectomy (1978) and silicone implant
placement (1985). Ultrasound con rms extracapsular silicone with a snowstorm
appearance.
CT can show both intracapsular and extracapsular ruptures. However, because CT
uses ionizing radiation, it is not the preferred method for evaluation of implants and
has not been studied systematically in this context.
The most reliable modality for detecting both intracapsular and extracapsular rup-
tures is MRI, which has been reported to have 95% to 98% sensitivity. A variety of
MR sequences have been used to evaluate the integrity of silicone implants.These
sequences have been devised to maximize differences between the silicone and the
normal fat and glandular tissues (water) of the breast.
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This 57-year-old patient presented for MRI evaluation of possible left implant rup-
ture. MRI examination was performed and con rmed intracapsular and extracap-
sular left implant rupture. Note extruded silicone in breast tissue (arrows).

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A typical implant magnetic resonance examination usually includes a sagittal local-
izing sequence done with a fast-spin echo (FSE) T2-weighted technique, axial T2-
weighted FSE sequences with water suppression, axial T1-weighted sequences with
silicone suppression and an axial short T1 inversion recovery (STIR) sequence with
water suppression. With a double breast coil and using a 1.5 Tesla scanner, these
four sequences can provide excellent imaging of both breast implants in 30 minutes
or less.37
T2-weighted FSE sequences of an intact silicone implant show the silicone as an
area of high signal surrounded by a hypodense line representing the envelope and
surrounding brous capsule. Infoldings of the hypodense line that are demonstra-
ble on sequential images as continuous with the envelope/capsule line are called ra-
dial folds, are commonly seen, and are not indications of rupture.
When leakage of silicone occurs in small amounts, silicone may be trapped within
folds of the implant shell producing the so-called keyhole (teardrop, inverted
teardrop, or noose) sign.38 Unlike radial folds, which always connect with the pe-
riphery of the implant, silicone is seen on both the inside and the outside of the fold
in the keyhole sign. Larger amounts of leakage produce the linguine sign, in which
the collapsed and folded implant shell is seen as serpiginous strands of low-signal in-
tensity oating within the high signal intensity silicone gel that is maintained in
place by the brous capsule39 (see p. 1491). In double-lumen implants, the pres-
ence of saline droplets oating in the silicone gel is the equivalent of intracapsular
rupture of a single-lumen implant.
Extracapsular rupture is manifest as silicone separate from the remainder of the im-
plant extending into breast parenchyma, along the pectoral muscle, and into axillary
lymph nodes. Signs of intracapsular rupture will also be seen when extracapsular
rupture has occurred (see p. 1495).
THE REDUCED OR LIFTED BREAST
Breast reduction is usually performed on women with very large breasts (macro-
mastia). The definition of what constitutes macromastia varies, but health insur-
ers will often cover procedure costs in women in whom appropriate volumes of
Signal Characteristics
Pulse Sequence
Silicone
Fat
Water
FSE T2-weighted
Bright
Intermediate
Very bright
FSE T2-weighted water suppressed
Bright
Intermediate
Dark
FSE T1-weighted silicone suppressed
Very dark
Dark
Intermediate
STIR
Bright
Dark
Very bright
STIR fat suppressed
Bright
Dark
Dark
Three-point Dixon, silicone only
Bright
Dark
Dark
FSE, Fast spin echo; STIR, short T1 inversion recover.

breast tissue are removed and who also have significant associated symptoms such
as neck and back pain, grooving of the shoulders from bra straps, and submam-
mary intertrigo.
In appropriately selected patients, reduction mammaplasty may also be used as the
operation of choice for women with or at high risk for breast cancer. One large-
scale study has shown a 50% to 70% decrease in breast cancer among women who
had reduction mammaplasties.40 Reduction to achieve symmetry is also commonly
performed on the contralateral breast after postmastectomy breast reconstruction.
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Bilateral MLO and CC views, bilateral 20-degree oblique, and axillary views are
shown from a 58-year-old patient 6 months after left mastectomy with TRAM re-
construction and a right reduction mammaplasty.
Surgical techniques for breast reduction and mastopexy are similar. Most involve a
combination of three incisions: A vertical incision from the nipple to the infra-
mammary fold along the 6-o’clock axis of the breast, an incision along the infra-
mammary fold, and a circumareolar incision.The scars produced by these incisions
are quite distinctive, and recognition by the experienced mammographer of the

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previous surgery is not a problem in most cases.41,42 Redistribution of the breast
parenchymal tissue is usually clearly evident on the x-ray mammogram.
This patient is shown after reduction mammaplasty.The alterations of parenchymal
distribution occur in nonanatomic fashion but are usually bilaterally symmetrical.
Residual broglandular tissue often is transposed from its normal upper outer quad-
rant position toward the lower half of the breast. Bandlike configurations of
parenchyma, long linear strands, and a whorled pattern of the residual parenchyma
are common. Skin thickening is usually evident in the infraareolar area.The bilat-
eral symmetry of the ndings and nonanatomic alterations in the parenchymal pat-
tern are clues that the parenchymal distortion is postsurgical rather than neoplastic.
Methods of reduction mammaplasty have been devised that can be accomplished
with fewer incisions and resultant scars.These include vertical incisions, liposuction
techniques, and periareolar incisions. Of these, the Goes “double-skin” periareolar
technique is of interest from the imaging standpoint as mesh is often used to main-
tain breast contour.The mesh is visible on mammography as a thin (less than 0.2 mm)
line beneath the skin. It is otherwise imperceptible and does not impede detection of
breast abnormalities.In general,scarring and redistribution of parenchyma are less ap-
parent than in standard reduction mammaplasties.43
Dystrophic calci cations along scars or elsewhere in breast parenchyma commonly
occur after reduction mammaplasty as do other manifestations of fat necrosis:lucent
areas (oil cysts) with or without calci cation and spiculated soft tissue densities that
are usually of low density. In the early stages, when calci cations are still ne or
when spiculation is not accompanied by distinctive coarse calci cations, differen-
tiation from carcinoma may not be possible, and biopsy may be indicated.

This bilateral mammogram 6 months postoperatively demonstrates the bilateral
scars. On ultrasound, hypoechoic fat necrosis and oil cysts are seen. This 29-year-
old patient is shown 6 months after breast reduction mammaplasty with bilateral
lumps and a history of postsurgical infection in the right breast. On the right, be-
low, a right craniocaudal mammographic image of an oil cyst is shown.
Epidermal inclusion cysts are also found in breasts that have undergone reduction
mammaplasty.44 These cysts occur when infolding of the dermis during reposition-
ing of the nipple-areola complex results in inclusion of some epidermal elements.
Such cysts commonly develop along the inframammary incision or the vertical in-
fra-areolar incision.They are usually nonpalpable and radiographically are depicted
as well-de ned noncalci ed nodules.They often contain internal echoes on ultra-
sonography, mimicking solid masses. Rupture of an epidermal inclusion cyst may
produce a pericystic inflammatory reaction, simulating the appearance of carci-
noma on x-ray mammography. Knowledge of the usual location and appearance of
these cysts may be suf cient for diagnosis. Stereotactic or ultrasonographic-guided
ne-needle aspiration or core biopsy may be used if a more de nitive diagnosis is
deemed necessary.
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THE RECONSTRUCTED BREAST
Reconstruction may be performed with a tissue expander (implant) or by transfer
of a musculocutaneous ap, most often from the rectus abdominis muscle. Other
donor sites include the latissimus, lateral thigh, gluteus, gracilis and periiliac fat
(Ruben’s ap).
This breast cancer patient is shown after mastectomy with gluteal reconstruction.
Masses in the reconstructed breast may occur as a result of fat necrosis, epidermal
inclusion cysts, or chest wall recurrence. In cases in which breast tissue has not been
completely excised, a true local breast recurrence is possible. TRAM ap recur-
rences are fortunately uncommon. In seven studies45-51 involving 1268 patients, re-
currences occurred in only 5.5% of patients undergoing breast reconstruction. Re-
currences appear to be more frequent in women who have had skin-sparing
mastectomies and in women whose original tumors were extensive ductal carci-
noma in situ.
1988, 1 year after surgery
1989, 2 years after surgery

This 49-year-old patient is shown 5 years after a left mastectomy with TRAM re-
construction for multicentric carcinoma with an enlarging irregular skin nodule.
Mammography con rms the nodule (arrow). Needle biopsy of the lesion con rmed
recurrent carcinoma.
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Imaging Considerations in Plastic Surgery of the Breast
Bilateral mediolateral oblique view
Bilateral 20-degree mediolateral oblique view
Palpable nodule
Bilateral craniocaudal view
Axilla

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R EOPERATIVE SURGERY OF THE BREAST AND CHEST WALL
Mammography is an excellent way of depicting the changes of fat necrosis in the
reconstructed breast and may have some utility in the investigation of postoperative
breast pain or other complications in these patients.Whether it should be routinely
done for detection of recurrence remains controversial.52
Chest wall recurrence after mastectomy occurs at the rate of 0.2% to 1% per year.
Asymptomatic chest wall recurrence may be detectable with mammography in
women who have had breast reconstructions.True recurrences in the TRAM ap
can also be detected before they become palpable. Whether survival is affected by
earlier detection of either chest wall or in-TRAM recurrences is unproven. Still, lo-
cal control should be easier to achieve in such cases and thus mammography may be
warranted. Other potentially more sensitive (and expensive) techniques such as CT,
MRI, and scintimammography are likely not indicated other than in a study setting.
Development of masses (usually caused by fat necrosis) in the reconstructed breast
is common and is certainly worrisome to the patient and her physicians when it oc-
curs. For this reason, a baseline postoperative x-ray mammogram of the recon-
structed breast is suggested 1 year after surgery.Whether such mammograms should
be repeated annually or only at the onset of symptoms remains to be established.
PREOPERATIVE IMAGING EVALUATION
For women with an average risk of breast cancer, mammographic screening for
breast cancer is initiated at age 40 in the United States. Women at exceptionally
high risk, such as those who are known to carry genes associated with breast can-
cer, those with histories of premenopausal breast cancer, and those who have had
chest wall radiotherapy before age 30 for treatment of lymphoma, should initiate
screening at a younger age. There is no argument that women undergoing breast
cosmetic surgery who have not yet had a mammogram and meet screening guide-
lines should have a preoperative mammogram.53
The average age of women undergoing augmentation mammaplasty is 32, with in-
creasing numbers of procedures being performed each year in women in their teens
and twenties. There are no data to suggest that women who undergo cosmetic
breast surgery are at higher risk for development of breast cancer at an early age
than other women.54 Thus there is little sense in performing routine preoperative
x-ray mammography on women in their twenties before cosmetic breast surgery.
The probability that a 20-year-old American woman will develop breast cancer in
her third decade is less than 0.07%.55 The chance of an American woman getting
a diagnosis of breast cancer in her thirties is 1 in 229. Although this risk is not high
enough to recommend routine screening of women in this age group, it may be ar-
guably high enough to recommend a preoperative mammogram for women hav-
ing cosmetic surgery in this age group.
If an abnormality is suspected on preoperative physical examination of the breasts,this
should be investigated regardless of the patient’s age. In women in their twenties and
early thirties, ultrasonography is the initial diagnostic imaging modality for a palpa-

ble breast mass. If a simple cyst is found, an x-ray mammogram may be unnecessary.
Ultrasonography is capable of identifying breast cysts with nearly 100% accuracy.Un-
less the cyst is symptomatic, further intervention is unnecessary. In young women
with a dominant breast mass, broadenoma is more likely to be the cause than cys-
tic disease. Because the ultrasonographic appearance of broadenoma may mimic a
well-circumscribed carcinoma, opinion is divided as to whether all such lesions re-
quire biopsy.This decision may be less problematic in the case of women undergo-
ing cosmetic breast surgery in that excisional biopsy of a palpable solid mass can usu-
ally be performed at the time of the scheduled cosmetic procedure. Alternatively,
ne-needle aspiration cytology or core biopsy may provide de nitive diagnosis if ex-
cisional biopsy is deemed undesirable.In cases in which a palpable abnormality is not
depicted on ultrasonography or the ultrasonographic ndings are suspicious for ma-
lignancy, an x-ray mammogram should be performed regardless of the patient’s age.
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Imaging Considerations in Plastic Surgery of the Breast
This patient who underwent mastectomy with right saline implant reconstruction
and left saline implant augmentation presented with new palpable left masses. Core
biopsy revealed multifocal invasive ductal carcinoma.
Bilateral mammograms
Implant displacement
Magni cation of palpable nodule
Ultrasound

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R EOPERATIVE SURGERY OF THE BREAST AND CHEST WALL
DETECTION OF BREAST CANCER
IN THE COSMETICALLY ALTERED BREAST
Women who have had their breasts injected with either paraf n or silicone or who
have had extensive leakage of silicone into breast tissue have the unfortunate distinc-
tion of being in a group for which neither x-ray mammography nor ultrasound has
much utility.For both screening and diagnostic purposes,breast MRI is the best avail-
able alternative. Radionuclide scintimammography using technetium 99m-sestamibi
is another method that can be used in such cases.
For all other women, mammography remains the primary imaging method for
breast cancer detection. Although there have been much publicized studies that
have suggested women with implants have a higher incidence of breast cancer or
have more advanced breast cancers at detection, neither of these suggestions has
been supported by large scale studies.56,57 Nonetheless, mammography and ultra-
sound both have signi cant limitations in the implanted breast and MR may be
helpful in evaluation of implant patients with indeterminate imaging ndings or
strong clinical suspicion of breast cancer without con rmatory ndings utilizing
standard imaging methods.
MRI techniques for evaluation of breast cancer differ from those needed for eval-
uation of implant integrity. Protocols for breast cancer detection require sequences
performed before and after the administration of contrast medium, most commonly
gadolinium.Subtraction images and/or kinetic sequences that allow graphic demon-
stration of contrast uptake curves in identi ed lesions are generally needed.
Once an abnormality is identi ed on contrast-enhanced MRI, it may be identi -
able at so-called second-look ultrasound making percutaneous biopsy with ultra-
sound guidance an option. If the lesion still cannot be located by ultrasound, a per-
cutaneous biopsy must be performed with MRI guidance—a more complicated
and time-consuming biopsy method.
In women who have had either reduction mammaplasty or TRAM ap reconstruc-
tion, the breast tissue is usually predominantly fatty, and x-ray mammography is the
procedure of choice for breast cancer screening and diagnosis. The risk of breast
cancer in reduction mammaplasty patients is somewhat lower than in the general
population,with estimates ranging from 0.05% to 1.66 %.58,59 The reduction in breast
cancer risk is thought to be proportional to the amount of breast tissue removed.60

CONCLUSION
Currently there is no diagnostic imaging method that surpasses the x-ray mam-
mogram for evaluation of diseases of the breast. Mammography provides helpful in-
formation both in symptomatic (diagnosis) and asymptomatic (screening) women.
Women whose breasts have been altered by plastic surgery provide special problems
in diagnostic imaging. Modi ed imaging techniques are now available to maxi-
mize the amount of breast tissue visible in the presence of a breast implant.
The veri cation of implant integrity is a problem unique to the woman who has
undergone augmentation with a silicone gel prosthesis. Initial imaging of women
with suspicion of this complication should consist of an x-ray mammogram with
standard and displacement techniques. If extracapsular rupture is demonstrated, fur-
ther imaging is unnecessary. If ndings suspicious for carcinoma are found, addi-
tional mammographic views and/or ultrasonography should be performed. If x-ray
mammography is negative or indeterminate and there is clinical suspicion of rup-
ture, ultrasonography is the examination of choice. Ultrasonography may con rm
rupture or identify a mass not visible on x-ray mammogram and is considerably less
costly than other alternatives. If ultrasonography fails to elucidate the situation,
MRI should be performed, because it is the best available method for the detection
of intracapsular rupture and anatomic depiction of the location of extruded silicone
relative to vital structures.
Women who have had cosmetic breast surgery and who are of an appropriate age
should undergo screening mammograms according to currently accepted guide-
lines.The age at which preoperative mammography should be performed should be
based on risk assessment in the individual patient but is generally not indicated for
women under age 30.
Some of the changes that occur in the postoperative breast mimic those of breast
carcinoma. Recognition of the expected changes following augmentation, reduc-
tion, and reconstruction mammaplasty should avoid the need for biopsy for most
benign postsurgical abnormalities. The use of additional views, spot compression,
and magni cation can and should be performed in the postsurgical breast when in-
dicated for evaluation of breast lesions detected clinically or by mammography. Ul-
trasonography is particularly useful in the evaluation of palpable masses in patients
with breast implants but should be used as an adjunct and not as a substitute for
x-ray mammography.With careful attention to detail and knowledge of the alter-
ations that may occur as a result of the various surgical procedures, the diagnosis of
disease (both clinical and occult) in the cosmetically altered breast should not be
compromised.
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References—With Key Annotated References
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21. Silverstein MJ, Handel N, Gamagami P, et al. Mammographic measurements before and after
augmentation mammoplasty. Plast Reconstr Surg 86:1126, 1990.
22. Barker D, Retsky M, Schultz S.“Bleeding” of silicone from bag-gel breast implants and its clin-
ical relation to brous capsule reaction. Plast Reconstr Surg 61:836, 1978.

23. Anderson B, Hawtof D, Alani H. The diagnosis of ruptured breast implants. Plast Reconstr
Surg 84:903, 1989.
24. Brown SL, Silverman BG, Berg WA. Rupture of silicone-gel breast implants: Causes, sequelae
and diagnosis. Lancet 350:1531, 1997.
25. Lovich SF, Meland NB. Breast implants and air ight. Plast Reconstr Surg 84:172, 1990.
26. Brown SL, Ferlo TJ, Luu H-MD. Breast implant adverse events during mammography:Reports
to the Food and Drug Administration. J Womens Health 13:379, 2004.
27. Robinson OG, Bradley EL, Wilson DS. Analysis of explanted silicone implants: A report of
300 patients. Ann Plast Surg 34:1, 1995.
28. van Rappard JHA, Sonneveld GJ, van Twisk R, et al. Pressure resistance of breast implants as a
function of implantation time. Ann Plast Surg 21:566, 1988.
29. Leibman J, Korsoff MB, Kruse BD. Intraductal extension of silicone from a ruptured breast
implant. Plast Reconstr Surg 89:546, 1992.
30. Young VL, Bartell T, Destouet JM, et al. Calci cation of breast implant capsule. South Med J
82:1171, 1989.
31. Mendelson EB. Evaluation of the postoperative breast. Radiol Clin North Am 30:107, 1992.
32. Soo MS, Kornguth PJ,Walsh R, et al. Complex radial folds versus subtle signs of intracapsular
rupture of breast implants. AJR Am J Roentgenol 166:1421, 1997.
33. Venta LA, Salomon CG, Flisak ME. Sonographic signs of breast implant rupture. AJR Am J
Roentgenol 166:1413, 1996.
34. DeBruhl ND, Gorczyca D, Ahn CY, et al. Silicone breast implants: US evaluation. Radiology
189:95, 1993.
35. Caskey CI, Berg WA, Anderson ND, et al. Breast implant rupture:Diagnosis with US. Radiol-
ogy 190:819, 1994.
36. Rosculet KA, Ikeda DM, Forrest ME, et al. Silicone implant rupture: Detection with US. Ra-
diology 187:761, 1993.
37. Liberman L, Berg WA. Magnetic resonance imaging in women with breast implants. In Mor-
ris EA, Liberman L, eds. Breast MRI: Diagnosis and Intervention. New York: Springer, 2005,
pp 238.
This is an excellent overview of imaging considerations related to detection of rupture and breast can-
cer in women with breast implants. Although the focus is MRI, the contributions of mammography
and ultrasound are also described.
38. Mund DF, Farria DM, Gorczyca DP, et al. MR imaging of the breast in patients with silicone-
gel implants: Spectrum of ndings. AJR Am J Roentgenol 161:773, 1999.
39. Gorczyca DP, Sinha S, Ahn C, et al. Silicone breast implants in vivo: MR imaging. Radiology
185:407, 1992.
40. Boice JD, Person I, Brinton LA, et al. Breast cancer following breast reduction surgery in Swe-
den. Plast Reconstr Surg 106:755, 2000.
41. Miller CL, Feig SA, Fox JW IV. Mammographic change after reduction mammoplasty. AJR
Am J Roentgenol 149:35, 1987.
42. Buhtz C, Freitag J, Berge G, et al. [Mammographic ndings following reduction mammaplasty]
Zentralbl Chir 114:36, 1989.
43. Goes JC,Landecker A,Lyra EC, et al.The application of mesh support in periareolar breast sur-
gery: Clinical and mammographic evaluation. Aesthetic Plast Surg 28:268, 2004.
44. Fajardo LL, Bessen SC. Epidermal inclusion cyst after reduction mammoplasty. Radiology
186:103, 1993.
45. Singletary SE. Skin-sparing mastectomy with immediate breast reconstruction:The M.D. An-
derson Cancer Center experience. Ann Surg Oncol 3:411, 1996.
46. Noone RB, Frazier TG, Noone GC, et al. Recurrence of breast carcinoma following immedi-
ate reconstruction: A 13-year review. Plast Reconstr Surg 93:96, 1994.
47. Johnson CH, van Heerdon JA, Donohue JH, et al. Oncological aspects of immediate breast re-
construction following mastectomy for malignancy. Arch Surg 124:819, 1989.
1507
Chapter 38
Imaging Considerations in Plastic Surgery of the Breast

1508
PART IV
R EOPERATIVE SURGERY OF THE BREAST AND CHEST WALL
48. Kroll SS, Schusterman MA,Tadjalli HE, et al. Risk of recurrence after treatment of early breast
cancer with skin-sparing mastectomy. Ann Surg Oncol 4:193, 1997.
49. Slavin SA, Love SM, Goldwyn RM. Recurrent breast cancer following immediate reconstruc-
tion with myocutaneous aps. Plast Reconstr Surg 93:1191, 1994.
50. Shaikh N, LaTrenta G, Swistel A, et al. Detection of recurrent breast cancer after TRAM ap
reconstruction. Ann Plast Surg 47:602-607, 2001.
51. Helvie MA, Bailey JE, Roubidoux MA, et al. Mammographic screening of TRAM ap breast
reconstructions for detection of nonpalpable recurrent cancer. Radiology 224:211, 2002.
This paper is the best overview of imaging related to the TRAM reconstructed breast.The authors’
bias is that mammographic imaging should be routinely performed in this setting.
52. Eidelman Y, Liebling RW, Buchbinder S, et al. Mammography in the evaluation of masses in
breast reconstructed with TRAM aps. Ann Plast Surg 41:229, 1998.
53. Snodgrass K,Yu J, Doster E, et al. The value of preoperative mammograms in nononcologic
breast surgery. South Med J 90:402, 1997.
54. Brinton LA, Lubin JH, Murray MC, et al. Mortality among augmentation mammoplasty pa-
tients: An update. Epidemiology 17:162, 2006.
This is the most recent large-scale (12,144 patients) epidemiologic survey of causes of death in the
breast implant population.The study shows an overall decrease in mortality related to the general pop-
ulation and no excess risk of breast cancer. Interestingly, excess risk of death from suicide and motor
vehicle accident was evident in this 18-year follow-up study.
55. Ries LAG, Eisner MP, Kosary CL, et al, eds. SEER Cancer Statistics 1975-2002. Bethesda, MD:
National Cancer Institute, 2005.
56. Bryant H, Brasher P. Breast implants and breast cancer-reanalysis of a linkage study. N Engl J
Med 326:1649, 1999.
57. McLaughlin JK, Lipworth L, Fryzek JP, et al. Long-term cancer risk among Swedish women
with cosmetic breast implants: An update of a nationwide study. J Natl Cancer Inst 98:557,
2006.
58. Tarone RE, Lipworth L,Young VL, et al. Breast reduction surgery and breast cancer risk:Does
reduction mammoplasty have a role in primary prevention strategies for women at high risk
of breast cancer? Plast Reconstr Surg 113:2104-2110, 2004.
This review of more than 70,000 women with reduction mammaplasties showed an apparent 50%
to 70% lowering of breast cancer risk suggesting the potential value of the procedure as a risk reduc-
tion procedure.
59. Hage JJ, Karim RB. Risk of breast cancer among reduction mammoplasty patients and the
strategies used by plastic surgeons to detect such cancer. Plast Reconstr Surg 117:727, 2006.
60. Brinton LA, Persson I, Boice JD, et al. Breast cancer risk in relation to amount of tissue re-
moved during breast reduction operations in Sweden. Cancer 91:473, 2001.

1509
Chapter 38
Imaging Considerations in Plastic Surgery of the Breast
1.Typical mammographic appearance of paraf noma includes:
a. Streaky opacity in midbreast glandular tissue
b. Architectural distortion
c. Multiple dense nodules
d. All of the above
2. Complications of paraf n injections are:
a. In ammatory response
b. Tissue necrosis
c. Draining sinus tracts
d. All of the above
3. Subglandular implants:
a. Produce a more natural contour
b. Produce a more voluminous augmentation than subpectoral implants
c. Are easier to place
d. All of the above
4. Subpectoral implants:
a. Allow imaging of a greater volume of breast tissue
b. Have a signi cantly lower rate of capsular contracture
c. Have a lower rate of loss of nipple sensation
d. All of the above
5. Implant abnormalities include:
a. Displacement
b. Contour deformities
c. Encapsulation
d. Collapse
e. All of the above
R EVIEW QUESTIONS

(Trang không có chữ)

1511
Local Recurrence After Mastectomy
and Breast Reconstruction
Sumner A. Slavin and Anne G.Warren
C ha pter 3 9
Reoperative Problems
Metastasis
Incomplete resection of tumor at mastectomy
Carcinoma en cuirasse
Irradiated chest wall
Time heals old pain,
while it creates new ones.
Hebrew proverb
Local recurrence of breast cancer after mastectomy is de ned as a biopsy-proven
cancer located in the mastectomy skin aps, transposed tissues, or ipsilateral chest
wall. Although local recurrenceis often used interchangeably with locoregional recurrence,
there have been recent shifts toward more concrete delineation of the two, with the
term regional recurrence reserved for recurrent tumor involvement of the ipsilateral
axillary or supraclavicular lymph nodes.1
When local recurrence occurs after mastectomy, the majority of tumors are found
in the skin or subcutaneous tissues of the mastectomy aps;recurrences in the chest
wall are less common. Numerous studies have examined the role of mastectomy
technique in the development of in-breast recurrence. However, no clinically sig-
ni cant differences have been de nitively identi ed, which has allowed the devel-

1512
PART IV
R EOPERATIVE SURGERY OF THE BREAST AND CHEST WALL
opment of alternative approaches to traditional radical mastectomy as a means of
decreasing surgical morbidity and improving aesthetic outcome. Although the pos-
sibility of increased risk of local recurrence with reconstruction of the breast after
mastectomy was initially suggested, further study demonstrated that postmastec-
tomy breast reconstruction, the type of reconstruction, and the timing of recon-
struction had no effect on the patient’s oncologic outcome.2 These ndings support
the theory that local recurrence can be viewed as a marker for the presence of
systemic disease, which also results in the poor patient prognosis seen after local
failure.
RISK FACTORS FOR LOCAL RECURRENCE
A number of factors have been examined to identify risk factors for in-breast recur-
rence after mastectomy. Tumor characteristics found to be associated with higher
rates of local recurrence include primary tumor size greater than 2 cm, lymph node
involvement, poor tumor differentiation, negative hormone receptor status, and
skin involvement, as manifested through skin xation, clinical invasion, or skin ul-
ceration.3 Although overall local recurrence rates after mastectomy and breast re-
construction are typically reported to be 5% to 10%, many of these cases represent
patients with stage II or III disease, with local recurrence occurring very rarely in
women with less progressive disease.
ORIGINS OF LOCAL RECURRENCE
Paradigms for the mechanism of breast cancer recurrence have shifted over time
from a focus on spread through localized lymphatics and invasion into the system-
atic vasculature to theories involving micrometastases. Considering local failure as
an indication of systemic disease, however, local recurrence of breast cancer most
likely represents a heterogeneous process secondary to both local and systemic fac-
tors. Most recurrent lesions are likely attributable to the following mechanisms:
Unrecognized tumor or residual breast tissue resulting from inadequate ex-
cision remaining after mastectomy
Hematogenous circulation of tumor cells
Lymphatic dissemination of tumor cells by reconnection of local lymphatic
channels with tumor-infested lymphatic vessels or regeneration across adja-
cent normal tissues
Studies evaluating patterns of local recurrence after mastectomy have demonstrated
support for the components of a heterogeneous model of local recurrence. By em-
phasizing the role of tumor biology in local recurrence, advocates of skin-sparing
mastectomy, as well as the more controversial nipple-sparing mastectomy, have ad-
vanced the prevalence of these techniques and the improved cosmetic outcomes
that can subsequently be achieved in women undergoing reconstruction. Within
this theory, local recurrence after mastectomy is a manifestation of the inherent

1513
Chapter 39
Local Recurrence After Mastectomy and Breast Reconstruction
characteristics of the tumor and its propensity to recur and spread, such that aggres-
sive tumors will recur both locally and systemically regardless of the presence or ab-
sence of mastectomy skin aps. The negligible impact of mastectomy technique
on oncologic safety has been con rmed in multiple studies comparing rates of lo-
cal recurrence in patients undergoing traditional modi ed radical mastectomy with
those undergoing skin-sparing mastectomy, with no signi cant differences seen be-
tween groups.4-6 However, an additional role for local factors in tumor recurrence
is supported by the success of radiation therapy in improving both disease-free and
overall survival in patients after mastectomy, as well as the observation that some in-
breast recurrences managed locally without systemic chemotherapy can provide
patients with long-term tumor-free survival.7
METHODS FOR DETECTION OF LOCAL
RECURRENCE
Physical examination of the reconstructed breast and chest wall can, in most cases,
allow accurate diagnosis of local breast cancer recurrences. A local recurrence usu-
ally begins as a painless, erythematous rash or a solitary nodular lesion in the native
skin or subcutaneous tissues adjacent to the mastectomy scar, as above.The growths
have a cobblestone appearance caused by aggregates of tumor cells in the lymphatic
spaces of the dermis. As the tumor grows, the malignant cells spread rapidly through
the soft tissues, often forming a confluent firmness and thickening of the skin.
Given that deep submuscular or subpectoral chest wall recurrences are extremely
rare because nearly all local recurrences occur super cial to the pectoralis major, the
subcutaneous nodular growths seen in most cases of local recurrence are readily
apparent. Additionally, when deep chest wall recurrences do develop, the patient of-
ten presents with clinical symptoms resulting from local rib and muscle invasion.
However, even with the rare potential for these deep recurrences, the remote pos-
sibility that a subpectoral prosthesis or myocutaneous ap reconstruction would
impede detection in women who had undergone breast reconstruction must be
considered.

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PART IV
R EOPERATIVE SURGERY OF THE BREAST AND CHEST WALL
Because of the potential for these recurrences and the not insigni cant risk of lo-
cal recurrence after mastectomy, much attention has been given to the question of
screening women with routine imaging studies. Although the standard of care for
screening patients who have undergone breast conservation therapy involves annual
mammograms and routine clinical breast examinations, these guidelines have not
been recommended for postmastectomy patients. Additionally, outcome bene ts
from early detection of in-breast recurrence after mastectomy have been ques-
tioned, because the recurrence may just be an indication of aggressive disease caused
by speci c tumor biology; detection and treatment of the recurrence may not im-
prove disease-free or overall survival.
Although there is signi cant variability among practitioners regarding screening
women after mastectomy and breast reconstruction, when routine imaging studies
are incorporated, mammography is typically the initial technique used. Mammog-
raphy may be technically limited in patients after prosthetic implants. Despite this
limitation, standard mammographic views can be used in patients with autologous
tissue reconstructions with good visualization of breast pathology, particularly be-
cause much of the myocutaneous ap reconstruction is composed of adipose tissue,
which allows for optimal mammographic examination. A paucity of literature doc-
umenting the bene t of mammographic screening in women with breast recon-
struction is currently available. However, one study examining routine screening
using mammograms in asymptomatic women after mastectomy and transverse rec-
tus abdominis myocutaneous (TRAM) ap reconstruction has reported a sensitiv-
ity of 67% and a speci city of 98% in detecting nonpalpable recurrent cancer.8 The
use of ultrasound, CT, and MRI in patient follow-up after breast reconstruction
has also been suggested, but these modalities are typically reserved for symptomatic
patients who require directed study rather than as screening tools.
One limitation of using imaging studies to detect local recurrence is the potential
for elevated rates of false positive results as the result of postoperative changes within
the breast, particularly areas of fat necrosis. Fat necrosis, which has been reported in
as many as 30% of all TRAM ap reconstructions,9 can be mistaken for localized
malignancy caused by the widespread variability in the mammographic features as-
sociated with fat necrosis.10
Given the potential for misdiagnosis, all suspicious areas should be
biopsied, either by ne-needle aspiration or by open excision, to en-
sure adequate oncologic treatment when indicated.
PATIENT EXAMPLE
A 44-year-old woman with lobular carcinoma of the breast had a right modi ed
radical mastectomy performed in conjunction with immediate breast reconstruc-
tion using a TRAM ap.The initial postoperative course was uneventful. All drains
were removed on the fth postoperative day, when drainage from the abdominal
donor site was less than 30 ml/day.

1515
Chapter 39
Local Recurrence After Mastectomy and Breast Reconstruction
Six months later, an epigastric mass was noted when the patient complained of ab-
dominal discomfort and a sense of fullness. No weakness or hernia was identi ed,
but a mass measuring 8 by 10 cm was palpated.
A CT scan of the abdomen revealed a large, subcutaneous mass adherent to the
posterior sheath of the ipsilateral rectus abdominis muscle below the xiphoid
process.
An 8 by 10 cm epigastric cyst lled with a straw-colored uid was surgically re-
moved. Histologic examination revealed a benign cyst containing brinous mate-
rial. No further abnormalities have appeared since the cyst was excised.
In this patient the epigastric mass was presumed to be a local recurrence, possibly
resulting from dissemination of tumor cells from the mastectomy site to the exten-
sive abdominal donor tissues at the time of the immediate breast reconstruction.
Such spread of tumor has rarely, if ever, been reported in the literature. Neverthe-
less, the presence of a large mass raised the possibility of a local recurrence of breast
cancer in an area adjacent to the mastectomy site. Although the CT image indicated
a benign-appearing cyst, a similar lesion in another patient was explored and found

1516
PART IV
R EOPERATIVE SURGERY OF THE BREAST AND CHEST WALL
to harbor a recurrence of adenocarcinoma of the breast in the cyst wall.This clin-
ical example underscores the importance of con rming the precise histologic state
with a biopsy rather than by relying solely on imaging techniques.
LOCAL RECURRENCE AFTER MASTECTOMY
AND BREAST RECONSTRUCTION
Breast reconstruction after mastectomy has been shown to improve the psycho-
logical outcomes of women undergoing mastectomy and is associated with high
patient satisfaction. Re nement in the surgical management of breast cancer over
the years has led to the development of skin-sparing mastectomy (SSM).This tech-
nique has proved to be oncologically safe and has signi cantly improved cosmetic
outcomes after breast reconstruction, particularly with the advent of immediate re-
construction at the time of mastectomy. Local recurrence after SSM is typically re-
ported in 0% to 7% of cases,4,11,12 a rate consistent with that of conventional mas-
tectomy.5,13,14 Reconstruction with either a prosthetic implant or a myocutaneous
ap has not been shown to increase the incidence of local failure, although special
considerations may arise regarding detection and management of in-breast recur-
rences.
IMPLANT R ECONSTRUCTION
Reconstruction with prosthetic implants continues to be the most commonly per-
formed breast reconstruction procedure. Many reports have focused on the onco-
logic safety of implant reconstruction, particularly regarding rates of local failure and
the detection and treatment of local recurrences. Although many mechanisms for
a potentially increased risk of recurrence with implant placement had been ini-
tially conceived, reconstruction with implants does not compromise the ablative
procedure, open new tissue planes for dissemination of tumor cells, or inhibit the
body’s immune system. Additionally, theories that saline prostheses might aid tumor
growth have been disproved. Several small studies examining possible silicone gel
implant inhibition of antitumor immunity demonstrate no evidence of increased
potential for malignant spread. The lack of substantiated biologic mechanisms for
higher local recurrence rates has been mirrored in clinical studies that have shown
consistent rates among patients who have undergone mastectomy alone and pa-
tients who have undergone implant reconstruction. Similarly, no signi cant differ-
ences have been demonstrated between patients who have undergone delayed re-
construction and patients who have undergone immediate reconstruction.
In addition to concerns regarding tumor spread, much discussion has arisen regard-
ing detection of local recurrence in patients with implant reconstruction. Although
mammography can be challenging in patients with prosthetic implants, and routine
screening through imaging has not been recommended, detection of in-breast re-
currence through physical examination can be very effective, and may even be
more sensitive in patients with prostheses.This potential advantage draws from the
pattern of local recurrences, which are typically seen in the more super cial tissues

1517
Chapter 39
Local Recurrence After Mastectomy and Breast Reconstruction
of the breast rather than the deep chest wall. Given that the placement of pros-
thetic implants leads to increased stretch of the breast skin across the underlying
subcutaneous tissues, use of an implant reconstruction may push any tumor nodules
of the subcutaneous layers toward the skin surface and make them more easily pal-
pable, or even visible, thus allowing better detection.These mechanical factors may
also play a role in detection of deeper chest wall recurrences because placement of
a subpectoral implant leads to anterior displacement of the pectoralis major mus-
cle, thus making discovery of embedded tumor possible through palpation alone.
MYOCUTANEOUS FLAP R ECONSTRUCTION
Breast reconstruction techniques that use aps of myocutaneous tissue (for exam-
ple, latissimus dorsi or rectus abdominis) bring extensive amounts of soft tissue to
the mastectomy site. Given the tissue rearrangement and transfer involved in these
procedures, when local recurrence occurs confusion may arise as to the exact source
of the tumor recurrence. As in patients who have undergone mastectomy without
reconstruction, recurrences in patients with autologous tissue ap reconstruction
tend to present in the mastectomy skin aps or, less frequently, in the chest wall.
However, tumor may invade the myocutaneous ap from these other sites and be
detected through the ap involvement, thus obscuring the true origin of the recur-
rence.7 Although a rare occurrence,15 tumors can recur within the ap reconstruc-
tion. Multiple mechanisms of recurrence for these tumors have been considered.
These possibilities include the generation of new lymphatic channels across the
flap from native breast skin, and subsequent spread from tumor cells harbored
within lymphatics,16 as well as the possibility of tumor seeding with autologous
ap transfer.
Considering the myocutaneous tissue bulk needed for breast reconstruction after
mastectomy, questions have been raised as to whether an autologous reconstruction
might conceal an in-breast recurrence from detection on physical examination,
particularly in cases of deep chest wall recurrences. This problem has not been
demonstrated in studies examining the possibility of delayed diagnosis of local re-
currence or decreased survival rates in patients undergoing myocutaneous ap re-
construction.16 However, routine mammographic follow-up as an adjunct to phys-
ical examination in patients with a history of prior breast reconstruction is often
suggested. Because of the success of this technique in detecting nonpalpable local
recurrences,8 this screening strategy may prove ineffective for patients with autol-
ogous breast reconstructions.
PATIENT EXAMPLE
A 42-year-old woman had a history of in situ carcinoma of the left breast that was
treated by partial mastectomy and radiation therapy. Two years later, she was diag-
nosed with in ammatory carcinoma of the right breast and was referred for mas-
tectomy of the right breast and immediate reconstruction with a TRAM ap. She
was treated initially with chemotherapy and a course of 50 Gy to the left breast, but

1518
PART IV
R EOPERATIVE SURGERY OF THE BREAST AND CHEST WALL
the tumor persisted. It was determined that mastectomy would offer her the best
opportunity for local control.
The right breast and extensive portions of the cutaneous surface of the right
hemithorax were resected. Tumor cells were present in the dermal lymphatic sys-
tem and in five of six lymph nodes. The breast was reconstructed with a large
TRAM ap measuring 16 by 35 cm.
Seven months later, an erythematous rash and multiple nodular lesions developed
in the native skin of the chest wall adjacent to the mastectomy scar and musculo-
cutaneous ap reconstruction. Biopsy of these lesions demonstrated cancer within
the dermal lymphatic spaces, but clinical staging, including CT imaging of the chest
and abdomen, did not show any evidence of distant metastasis.
A new mass that developed in the left breast was found to be intraductal carci-
noma, necessitating a left salvage mastectomy and reconstruction with a left latis-
simus dorsi musculocutaneous ap. Eighteen months after the diagnosis of in am-
matory cancer of the right breast, metastases to the lung and spine were found.
After undergoing additional chemotherapy regimens, she lived 3 more years and -
nally succumbed to metastatic carcinoma.
This case history illustrates the usual clinical presentation of recurrent breast carci-
noma after mastectomy and immediate reconstruction with a musculocutaneous
ap.
Although tumor nodules may involve extensive areas of the native
skin of the chest wall, distant metastases may not be detectable at the
time the skin lesions are diagnosed. However, distant disease can de-
velop quickly thereafter.
Most of these patients will be diagnosed with distant metastases within months to
1 to 2 years after the appearance of the local recurrence.

1519
Chapter 39
Local Recurrence After Mastectomy and Breast Reconstruction
TREATMENT OF LOCAL RECURRENCE
The controversy regarding treatment of the patient with local recurrence after mas-
tectomy includes areas of disagreement concerning the selection of modality and
the condition for treatment. Therapy typically involves optimizing treatment for
local control, which may entail local excision, radical excision, radiation therapy,
and/or chemotherapy. The variability in clinical presentations of locally recurrent
cancer has made it dif cult to assess the ef cacy of any single approach and most
studies present their results without strati cation by individual modality.17 For su-
per cially located lesions, excision with or without the addition of radiotherapy
can often be suf cient for treating an in-breast recurrence. However, if tumor re-
curs in the deeper tissues of the chest wall, the recurrence may represent isolated
metastases from mammary chain nodes and will require control with an expanded
radiation eld or chemotherapy. Other important considerations in managing pa-
tients with local recurrence include assessment of the presence of systemic disease
through a metastatic workup involving a bone scan and CT studies of the chest, ab-
domen, and pelvis, which should be performed in all patients presenting with lo-
cal recurrence. Additionally, patients with a prior history of breast or chest wall ra-
diation are not candidates for additional radiation therapy because of toxicity to
surrounding normal tissues.
Although scant data exist that speci cally examine appropriate treatment for pa-
tients experiencing in-breast recurrence after breast reconstruction, many of the
same management strategies guiding therapy in postmastectomy patients can be
applied. For patients who have undergone reconstruction with myocutaneous aps,
the need for removal of the tissue ap has been discussed. However, because many
recurrent lesions are localized to the chest wall adjacent to the mastectomy scar or
the breast reconstruction site, simple reexcision of the recurrence, with care to en-
sure negative margins, can often be performed with local rotation or advancement
aps taken from the reconstruction tissue in a manner virtually identical to the use
of native breast tissue for closure in breast conservation therapy.
Recurrence after reconstruction with prosthetic implants can also be managed with
local excision and radiation therapy without requiring implant removal, although
cases of implant infection have been reported after surgical treatment of in-breast
tumor recurrence.18 Use of radiation therapy in the presence of prosthetic implants
has been shown to have no associated compromise of the therapy nor increased
rates of treatment morbidity. However, because of the reported adverse effects of ra-
diation therapy on cosmetic outcomes in patients undergoing radiation therapy af-
ter breast reconstruction, patients requiring extensive radiotherapy after local recur-
rence may elect for removal of their prosthesis or reconstructed tissue ap before
salvage therapy.

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PART IV
R EOPERATIVE SURGERY OF THE BREAST AND CHEST WALL
In cases of extensive lesions involving large cutaneous surfaces or invasion of deep
chest wall structures such as the ribs or sternum, a myocutaneous ap can be used
for wound closure after wide excision of the tumor.
Use of a musculocutaneous flap is particularly suitable when os-
teonecrosis has developed after radiation therapy, because these aps
provide both necessary vascularity and soft tissue elements.
If a myocutaneous abdominal ap (that is,TRAM ap, free TRAM ap, or deep in-
ferior epigastric perforator [DIEP] ap) has already been used for breast recon-
struction, an alternative ap donor site must be selected for closure of the wound.
The latissimus dorsi musculocutaneous unit is an excellent choice as either a mi-
crovascular free ap or as a pedicled graft in cases in which the patient has received
prior chest wall irradiation or has a large soft tissue defect.
If excision of local tumor recurrence creates a defect with dimensions that exceed
the availability of donor site skin, tissue expansion can provide signi cant increase
in the area of latissimus dorsi muscle available for reconstruction.

1521
Chapter 39
Local Recurrence After Mastectomy and Breast Reconstruction
After the local recurrence is resected, the expanded latissimus dorsi ap is re ected
back and then transposed into the wound.
The expanded aps are ideal for covering wounds of irradiated chest
walls in patients with or without locally recurrent breast cancer.
PROGNOSIS AFTER LOCAL RECURRENCE
The majority of long-term data regarding prognosis relates to patients who have
undergone mastectomy alone. However, these data can be extrapolated to the re-
construction population as well, given that breast reconstruction after mastectomy
has not been associated with differing disease-free or overall survival rates.19 Com-
pared with recurrence after breast conservation therapy, local failure after mastec-
tomy carries a much worse prognosis, which is likely related to the aggressive na-
ture of the tumors. Additionally, the time of onset of local recurrence has been
shown to correlate with the probability of distant metastases and overall survival.20
This information represents another component in the often dismal prognosis for
these patients, given that multiple studies examining the onset of local failure after
mastectomy have demonstrated average time of onset to be as short as 18 months.
As a result of these factors, the 10-year disease-free survival rate has been reported
in the range of 7% to 17% from the time of initial recurrence,21-23 with the overall
survival rate at 26% to 32%.1
Although tumor characteristics, including tumor stage,3 location of recurrence,7
and time to recurrence, have been associated with worse outcomes for patients,
few controllable factors have been identi ed that signi cantly improve patient prog-
nosis after local failure.The presence of local failure after mastectomy is highly cor-
related with tumor-related death24 and later onset of metastases; current treatment
options may not have a positive impact on these conditions. Because the major sig-
ni cance of local recurrence may be as a marker for underlying systemic disease, the
presence of an in-breast recurrence unfortunately predicts that the patient’s chance
of dying of metastatic breast cancer within 10 years is very high,25 although a small
fraction of patients with distant disease survive beyond this time period.

1522
PART IV
R EOPERATIVE SURGERY OF THE BREAST AND CHEST WALL
CONCLUSION
The incidence of local recurrence of breast cancer is not increased with breast re-
construction after mastectomy, and oncologic safety has been demonstrated in both
immediate and delayed reconstruction using multiple reconstructive approaches.
Although a variety of options and strategies for detection and treatment have been
implemented and reported, local failure is often an early sign of metastatic disease
that is notoriously refractory to treatment and associated with bleak long-term out-
comes.
References—With Key Annotated References
1. Clemons M, Hamilton T, Goss P. Does treatment at the time of locoregional failure of breast
cancer alter prognosis? Cancer Treat Rev 27:83, 2001.
2. Murphy RX Jr, Wahhab S, Rovito PF, et al. Impact of immediate reconstruction on the local
recurrence of breast cancer after mastectomy. Ann Plast Surg 50:333, 2003.
3. Carlson GW, Styblo TM, Lyles RH, et al. Local recurrence after skin-sparing mastectomy:Tu-
mor biology or surgical conservatism? Ann Surg Oncol 10:108, 2003.
4. Slavin SA, Schnitt SJ, Duda RB, et al. Skin-sparing mastectomy and immediate reconstruction:
Oncologic risks and aesthetic results in patients with early-stage breast cancer. Plast Reconstr
Surg 102:49, 1998.
5. Kroll SS, Khoo A, Singletary SE, et al. Local recurrence after skin-sparing and conventional
mastectomy: A 6-year follow-up. Plast Reconstr Surg 104:421, 1999.
6. Simmons RM, Fish SK, Gayle L, et al. Local and distant recurrence rates in skin-sparing mas-
tectomies compared with non-skin-sparing mastectomies. Ann Surg Oncol 6:676, 1999.
7. Langstein HN, Cheng MH, Singletary SE, et al. Breast cancer recurrence after immediate re-
construction: Patterns and signi cance. Plast Reconstr Surg 111:712, 2003.
This study was conducted to identify speci c patterns of local recurrence after reconstruction and to de-
termine their biologic signi cance.The data support the continued use of immediate breast reconstruc-
tion without fear of concealing a recurrence or in uencing the oncologic outcome.
8. Helvie MA, Bailey JE, Roubldoux MA, et al. Mammographic screening of TRAM ap breast
reconstructions for detection of nonpalpable recurrent cancer. Radiology 224:211, 2002.
The purpose of this study was to evaluate ndings from routine mammographic screenings in patients
with transverse rectus abdominis musculocutaneous (TRAM) ap reconstructions. Screening mammog-
raphy of breasts reconstructed with TRAM aps enables detection of nonpalpable cancer before clini-
cal examination.
9. Kroll SS, Gherardini G, Martin JE, et al. Fat necrosis in free and pedicled TRAM aps. Plast Re-
constr Surg 102:1502, 1998.
10. Shaikh N, LaTrenta G, Swistel A, et al. Detection of recurrent breast cancer after TRAM ap
reconstruction. Ann Plast Surg 47:602, 2001.
Breast cancer continues to be a signi cant cause of morbidity and mortality among women today.
The TRAM ap has played a substantial role in the reconstruction of defects secondary to mastectomy.
The most reliable forms of diagnosis of recurrent breast cancer after TRAM ap reconstruction remain
ne-needle, core, or open biopsy, if indicated.
11. Rivadeneira DE, Simmons RE, Fish SK, et al. Skin-sparing mastectomy with immediate breast
reconstruction: A critical analysis of local recurrence. Cancer J 6:331, 2000.
The purpose of this study was to provide follow-up data regarding the incidence of local breast can-
cer recurrence in patients undergoing skin-sparing mastectomy versus conventional non–skin-sparing
mastectomy methods.The use of skin-sparing mastectomy does not lead to an increase in local recur-

1523
Chapter 39
Local Recurrence After Mastectomy and Breast Reconstruction
rence rates when compared with conventional non–skin-sparing mastectomies and provides for im-
proved aesthetic results after immediate reconstruction.
12. Toth BA, Forley BG, Calabria R. Retrospective study of the skin-sparing mastectomy in breast
reconstruction. Plast Reconstr Surg 104:77, 1999.
13. Gerber B, Krause A, Reimer T, et al. Skin-sparing mastectomy with conservation of the nip-
ple-areola complex and autologous reconstruction is an oncologically safe procedure. Ann
Surg 238:120, 2003.
14. Carlson GW, Bostwick J, Stylbo TM, et al. Skin-sparing mastectomy: Oncologic and recon-
structive considerations. Ann Surg 225:570, 1997.
15. Chung SM, Shin SJ, Chen X, et al. Recurrent breast carcinoma arising in a transverse rectus ab-
dominis myocutaneous ap. Arch Pathol Lab Med 128:1157, 2004.
16. Slavin SA, Love SM, Goldwyn RM. Recurrent breast cancer following immediate reconstruc-
tion with myocutaneous aps. Plast Reconstr Surg 93:1191, 1994.
As immediate breast reconstruction with rectus abdominis and latissimus dorsi myocutaneous aps has
become a recognized technique for patients requiring mastectomy, concerns have arisen regarding the
detection and treatment of locoregional recurrence of breast cancer. From an oncologic viewpoint, the
technique of myocutaneous ap breast reconstruction with rectus abdominis or latissimus dorsi aps ap-
pears to be a safe one. An analysis of locoregional recurrence of breast cancer in patients undergoing
primary mastectomy or salvage mastectomy with myocutaneous ap breast reconstruction did not show
concealment by the ap of any recurrent tumor.
17. Clemons M, Danson S, Hamilton T, et al. Locoregionally recurrent breast cancer: Incidence,
risk factors, and survival. Cancer Treat Rev 27:67, 2001.
Locoregional recurrence (LRR) after therapy for early breast cancer is common. Patients with LRR
can suffer both local consequences and symptoms of metastatic disease because LRR is an indepen-
dent predictor of subsequent distant metastases. Much of the available data on LRR is derived from
small, single institution, retrospective studies, so marked differences in the incidence rates for LRR, its
risk factors, and subsequent systemic recurrence are reported.The purpose of this review was to try and
collate these data in a format that would be useful for clinicians and their patients.
18. Noone RB, Frazier TG, Noone GC, et al. Recurrence of breast carcinoma following immedi-
ate reconstruction: A 13-year review. Plast Reconstr Surg 93:96, 1994.
To evaluate the effect of immediate reconstruction on the incidence, location, detection, and treatment
of recurrent breast cancer, a review of 306 patients operated on according to a standard protocol dur-
ing 1979 through 1988 was performed. Reconstruction techniques included submuscular implants,
tissue expanders, and musculocutaneous aps.
19. Chagpar A, Langstein HN, Kronowitz SJ, et al.Treatment and outcome of patients with chest
wall recurrence after mastectomy and breast reconstruction. Am J Surg 187:164, 2004.
20. Moran MS, Haffty BG. Local-regional breast cancer recurrence: Prognostic groups based on
patterns of failure. Breast J 8:81, 2002.
21. Aberisk WJ, Sliver B, Henderson IC, et al.The use of radiotherapy for treatment of isolated lo-
cal-regional recurrence of breast carcinoma after mastectomy. Cancer 58:1214, 1986.
22. Mendenhall NP, Devine JW, Mendenhall WM. Isolated local-regional recurrence following
mastectomy for adenocarcinoma of the breast treated with radiation therapy alone or combined
with surgery and/or chemotherapy. Radiother Oncol 12:177, 1988.
23. Halverson KJ, Perez CA, Kuske RR. Survival following loco-regional recurrence of breast
cancer: Univariate and multivariate analysis. Int J Radiat Oncol Biol Phys 23:285, 1992.
24. Medina-Franco H, Vasconez LO, Fix RJ, et al. Factors associated with local recurrence after
skin-sparing mastectomy and immediate breast reconstruction for invasive breast cancer. Ann
Surg 235:814, 2002.
25. Gilliland MD, Barton RM, Copeland EM.The implications of local recurrence of breast can-
cer as the rst site of therapeutic failure. Ann Surg 197:284, 1984.

1524
PART IV
R EOPERATIVE SURGERY OF THE BREAST AND CHEST WALL
1. Which of the following factors has been associated with risk of local recurrence
of breast cancer after mastectomy?
a. Patient age
b. Tumor location
c. Tumor stage
d. Type of mastectomy performed
2. Typical rates of local recurrence after skin-sparing mastectomy are in which of
the following ranges?
a. 0% to 10%
b. 10% to 20%
c. 20% to 30%
d. 30% to 40%
3. Which of the following is the most common means of detecting local recur-
rence after implant reconstruction?
a. Screening mammogram
b. Clinical breast examination
c. Breast ultrasound
d. Breast MRI
4. Which of the following offers ideal management of a deep in-breast recurrence
extending into the ribs and sternum?
a. Local excision alone
b. Local excision and radiation therapy
c. Wide excision and myocutaneous ap transfer
d. Wide excision and chemotherapy
5. Patients who experience a local recurrence of breast cancer after mastectomy
can expect 10-year overall survival rates of which of the following?
a. 5% to 15%
b. 15% to 25%
c. 25% to 35%
d. 35% to 45%
R EVIEW QUESTIONS