Breast Reconstruction
Reconstruction Types
Breast reconstruction after mastectomy can be implant-based or autologous (tissue flap), or a combination.
Autologous Flap Reconstruction
TRAM Flap (Transverse Rectus Abdominis Myocutaneous)
- Pedicled flap from abdomen
- Muscular pedicle is seen with vascular supply
- Oil cysts and fat necrosis are common post-operatively
- Uses rectus abdominis muscle → higher risk of abdominal hernia
DIEP Flap (Deep Inferior Epigastric Perforator)
- Free flap from lower abdomen
- Completely disconnected from original blood supply and reattached to vessels in the chest
- Does NOT include the muscle
- Less morbidity than TRAM
- Shorter hospital stay than TRAM
- Maintains better perfusion due to sparing the rectus musculature
- Sparing the rectus musculature decreases the rate of abdominal hernias compared to TRAM
SIEA Flap (Superficial Inferior Epigastric Artery)
- Also a free flap from lower abdomen
- Removes a portion of skin and subcutaneous fat from lower abdomen
- Does NOT include the muscle (similar to DIEP)
Latissimus Dorsi Flap
- From the back
- Pedicled or free
Gluteal (Buttock) Flap
- Free flap from buttock
Board Pearl
DIEP and SIEA are both “free flaps” — completely disconnected from original blood supply and reattached to chest vessels. Both exclude muscle. DIEP/SIEA have less morbidity than TRAM because they spare the rectus musculature.
Pedicled vs. Free Flap
| Type | Definition | Examples |
|---|---|---|
| Pedicled | Remains attached to original blood supply | TRAM, Latissimus dorsi |
| Free | Completely disconnected + microsurgically reattached | DIEP, SIEA, gluteal flaps |
Implant-Based Reconstruction
See Breast Implants for details on implant types, complications, and imaging.
Acellular Dermal Matrix (ADM)
- Surgical mesh of either human or animal skin with cells removed (only collagen supporting structure remains)
- Creates an artificial internal soft tissue support
- Higher rate of complications than implant alone
- Better cosmesis
- May prevent capsular contracture and malpositioning
Tissue Expanders
- Placed after mastectomy
- Metal valve allows saline to be added over time
- May not be MRI compatible or may cause too much artifact
- Eventually exchanged for permanent implant
Imaging Considerations
Fat Necrosis
- Common post-operatively in all flap types
- Mimics cancer on all modalities
- Look for central fat on T1 non-fat-sat MRI sequence to confirm fat necrosis
- May need biopsy if no definite central fat
Seromas and Hematomas
- Common early findings
- Seromas should slowly resolve
- A seroma that increases in size after being stable → suspicious
Post-Operative Enhancement (MRI)
- Post-op changes and fat necrosis can enhance for up to 18 months on MRI
- Mass or non-mass enhancement near reconstruction site is concerning for recurrence
Screening After Mastectomy
- If all breast tissue is taken, does NOT require follow-up screening mammography
- Local recurrence in a tissue flap:
- Occurs in residual breast tissue, NOT the relocated flap fat
- Typically along subcutaneous scar line (skin-sparing mastectomy)
- Screening policy is controversial