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Breast Reconstruction with a Transverse Rectus Abdominis Myocutaneous Flap: Spectrum of Normal and Abnormal MR Imaging Findings¹

¹ From the Departments of Radiology (R.K.D., M.A.R., S.G.O.) and Pathology (C.M.), Hospital of the University of Pennsylvania, 3400 Spruce St, Philadelphia, PA 19104. Received November 28, 2003; revision requested February 6, 2004, and received March 23; accepted March 25. All authors have no financial relationships to disclose. Address correspondence to M.A.R. (e-mail: rosen@oasis.rad.upenn.edu).

View larger version (51K): [in a new window]   Figure 1a.  Pedicled TRAM flaps. Drawings show the surgical technique used for breast reconstruction with unilateral (a) and bilateral (b) pedicled TRAM flaps. The abdominal soft tissue is tunneled subcutaneously and placed in the mastectomy bed. Mesh reinforcement may be used in the abdominal defect.

View larger version (53K): [in a new window]   Figure 1b.  Pedicled TRAM flaps. Drawings show the surgical technique used for breast reconstruction with unilateral (a) and bilateral (b) pedicled TRAM flaps. The abdominal soft tissue is tunneled subcutaneously and placed in the mastectomy bed. Mesh reinforcement may be used in the abdominal defect.

View larger version (56K): [in a new window]   Figure 2.  Microsurgical free TRAM flap. Drawing shows the surgical technique used for breast reconstruction with a microvascular free TRAM flap, which is based on the inferior epigastric artery. Note that less of the rectus abdominis muscle is harvested.

View larger version (67K): [in a new window]   Figure 3a.  Normal appearance of a TRAM flap at MR imaging. (a) Axial T1-weighted image of both breasts shows complete fatty composition of the left breast. For comparison, note the normal glandular tissue in the right breast. (b) Sagittal T1-weighted image of the TRAM flap shows the atrophied rectus abdominis muscle anterior to the chest wall (*). The denuded dermal layer of the abdominal tissue (arrows) is seen parallel to the skin of the breast. (c) Corresponding mediolateral oblique mammogram shows the muscular pedicle (*).

View larger version (146K): [in a new window]   Figure 3b.  Normal appearance of a TRAM flap at MR imaging. (a) Axial T1-weighted image of both breasts shows complete fatty composition of the left breast. For comparison, note the normal glandular tissue in the right breast. (b) Sagittal T1-weighted image of the TRAM flap shows the atrophied rectus abdominis muscle anterior to the chest wall (*). The denuded dermal layer of the abdominal tissue (arrows) is seen parallel to the skin of the breast. (c) Corresponding mediolateral oblique mammogram shows the muscular pedicle (*).

View larger version (93K): [in a new window]   Figure 3c.  Normal appearance of a TRAM flap at MR imaging. (a) Axial T1-weighted image of both breasts shows complete fatty composition of the left breast. For comparison, note the normal glandular tissue in the right breast. (b) Sagittal T1-weighted image of the TRAM flap shows the atrophied rectus abdominis muscle anterior to the chest wall (*). The denuded dermal layer of the abdominal tissue (arrows) is seen parallel to the skin of the breast. (c) Corresponding mediolateral oblique mammogram shows the muscular pedicle (*).

View larger version (140K): [in a new window]   Figure 4a.  Skin thickening in a 41-year-old woman after TRAM flap reconstruction and radiation therapy. Sagittal T1-weighted (a) and T2-weighted (b) images of the reconstructed breast show radiation-induced skin thickening (large arrow), which appears as increased signal intensity in the dermal layer on the T2-weighted image (b). Note the fat necrosis in the superior breast (small arrow).

View larger version (122K): [in a new window]   Figure 4b.  Skin thickening in a 41-year-old woman after TRAM flap reconstruction and radiation therapy. Sagittal T1-weighted (a) and T2-weighted (b) images of the reconstructed breast show radiation-induced skin thickening (large arrow), which appears as increased signal intensity in the dermal layer on the T2-weighted image (b). Note the fat necrosis in the superior breast (small arrow).

View larger version (132K): [in a new window]   Figure 5a.  Seroma in a 45-year-old woman with pain after TRAM flap reconstruction. Sagittal T1-weighted (a) and T2-weighted (b) images of the reconstructed breast show a large fluid collection containing a fluid-fluid level in the lateral breast. Note that the patient was imaged in the prone position.

View larger version (109K): [in a new window]   Figure 5b.  Seroma in a 45-year-old woman with pain after TRAM flap reconstruction. Sagittal T1-weighted (a) and T2-weighted (b) images of the reconstructed breast show a large fluid collection containing a fluid-fluid level in the lateral breast. Note that the patient was imaged in the prone position.

View larger version (126K): [in a new window]   Figure 6a.  Fibrosis after TRAM flap reconstruction. Sagittal T1-weighted (a), T2-weighted (b), and delayed gadolinium-enhanced 3D subtraction GRE T1-weighted (c) images of the reconstructed breast show a spiculated mass (arrow) in the posterior breast. The mass demonstrates intermediate signal intensity on the T1-weighted image (a), low signal intensity on the T2-weighted image (b), and minimal delayed enhancement on the gadolinium-enhanced image (c).

View larger version (132K): [in a new window]   Figure 6b.  Fibrosis after TRAM flap reconstruction. Sagittal T1-weighted (a), T2-weighted (b), and delayed gadolinium-enhanced 3D subtraction GRE T1-weighted (c) images of the reconstructed breast show a spiculated mass (arrow) in the posterior breast. The mass demonstrates intermediate signal intensity on the T1-weighted image (a), low signal intensity on the T2-weighted image (b), and minimal delayed enhancement on the gadolinium-enhanced image (c).

View larger version (127K): [in a new window]   Figure 6c.  Fibrosis after TRAM flap reconstruction. Sagittal T1-weighted (a), T2-weighted (b), and delayed gadolinium-enhanced 3D subtraction GRE T1-weighted (c) images of the reconstructed breast show a spiculated mass (arrow) in the posterior breast. The mass demonstrates intermediate signal intensity on the T1-weighted image (a), low signal intensity on the T2-weighted image (b), and minimal delayed enhancement on the gadolinium-enhanced image (c).

View larger version (146K): [in a new window]   Figure 7a.  Fat necrosis and seroma in a 57-year-old woman with a palpable abnormality after TRAM flap reconstruction. (a) Sagittal T1-weighted image shows a high-signal-intensity lobulated mass in the upper breast (*). (b) Sagittal T2-weighted image shows that the mass is hypointense (*). A portion of a complex seroma posterior to the mass is also seen (arrow). (c) Sagittal gadolinium-enhanced 3D subtraction GRE image shows moderate peripheral enhancement of the mass (arrows). These findings are compatible with fat necrosis. (d, e) Corresponding mediolateral oblique (d) and craniocaudal (e) mammograms show that the mass is in the upper outer breast and is ovoid with central lucency (arrow). * = muscular pedicle.

View larger version (136K): [in a new window]   Figure 7b.  Fat necrosis and seroma in a 57-year-old woman with a palpable abnormality after TRAM flap reconstruction. (a) Sagittal T1-weighted image shows a high-signal-intensity lobulated mass in the upper breast (*). (b) Sagittal T2-weighted image shows that the mass is hypointense (*). A portion of a complex seroma posterior to the mass is also seen (arrow). (c) Sagittal gadolinium-enhanced 3D subtraction GRE image shows moderate peripheral enhancement of the mass (arrows). These findings are compatible with fat necrosis. (d, e) Corresponding mediolateral oblique (d) and craniocaudal (e) mammograms show that the mass is in the upper outer breast and is ovoid with central lucency (arrow). * = muscular pedicle.

View larger version (142K): [in a new window]   Figure 7c.  Fat necrosis and seroma in a 57-year-old woman with a palpable abnormality after TRAM flap reconstruction. (a) Sagittal T1-weighted image shows a high-signal-intensity lobulated mass in the upper breast (*). (b) Sagittal T2-weighted image shows that the mass is hypointense (*). A portion of a complex seroma posterior to the mass is also seen (arrow). (c) Sagittal gadolinium-enhanced 3D subtraction GRE image shows moderate peripheral enhancement of the mass (arrows). These findings are compatible with fat necrosis. (d, e) Corresponding mediolateral oblique (d) and craniocaudal (e) mammograms show that the mass is in the upper outer breast and is ovoid with central lucency (arrow). * = muscular pedicle.

View larger version (60K): [in a new window]   Figure 7d.  Fat necrosis and seroma in a 57-year-old woman with a palpable abnormality after TRAM flap reconstruction. (a) Sagittal T1-weighted image shows a high-signal-intensity lobulated mass in the upper breast (*). (b) Sagittal T2-weighted image shows that the mass is hypointense (*). A portion of a complex seroma posterior to the mass is also seen (arrow). (c) Sagittal gadolinium-enhanced 3D subtraction GRE image shows moderate peripheral enhancement of the mass (arrows). These findings are compatible with fat necrosis. (d, e) Corresponding mediolateral oblique (d) and craniocaudal (e) mammograms show that the mass is in the upper outer breast and is ovoid with central lucency (arrow). * = muscular pedicle.

View larger version (78K): [in a new window]   Figure 7e.  Fat necrosis and seroma in a 57-year-old woman with a palpable abnormality after TRAM flap reconstruction. (a) Sagittal T1-weighted image shows a high-signal-intensity lobulated mass in the upper breast (*). (b) Sagittal T2-weighted image shows that the mass is hypointense (*). A portion of a complex seroma posterior to the mass is also seen (arrow). (c) Sagittal gadolinium-enhanced 3D subtraction GRE image shows moderate peripheral enhancement of the mass (arrows). These findings are compatible with fat necrosis. (d, e) Corresponding mediolateral oblique (d) and craniocaudal (e) mammograms show that the mass is in the upper outer breast and is ovoid with central lucency (arrow). * = muscular pedicle.

View larger version (123K): [in a new window]   Figure 8a.  Local recurrence in a 31-year-old woman with a palpable abnormality after bilateral TRAM flap reconstruction. Sagittal T1-weighted (a), gadolinium-enhanced fat-saturated GRE T1-weighted (b), and subtraction (c) images of the reconstructed breast show a round mass just superior to the inframammary crease. The mass demonstrates solid enhancement on the gadolinium-enhanced image (arrow in b). Biopsy revealed poorly differentiated intraductal carcinoma.

View larger version (124K): [in a new window]   Figure 8b.  Local recurrence in a 31-year-old woman with a palpable abnormality after bilateral TRAM flap reconstruction. Sagittal T1-weighted (a), gadolinium-enhanced fat-saturated GRE T1-weighted (b), and subtraction (c) images of the reconstructed breast show a round mass just superior to the inframammary crease. The mass demonstrates solid enhancement on the gadolinium-enhanced image (arrow in b). Biopsy revealed poorly differentiated intraductal carcinoma.

View larger version (142K): [in a new window]   Figure 8c.  Local recurrence in a 31-year-old woman with a palpable abnormality after bilateral TRAM flap reconstruction. Sagittal T1-weighted (a), gadolinium-enhanced fat-saturated GRE T1-weighted (b), and subtraction (c) images of the reconstructed breast show a round mass just superior to the inframammary crease. The mass demonstrates solid enhancement on the gadolinium-enhanced image (arrow in b). Biopsy revealed poorly differentiated intraductal carcinoma.

View larger version (109K): [in a new window]   Figure 9a.  Nodal recurrence in a 50-year-old woman with an axillary mass after TRAM flap reconstruction. Axial T1-weighted (a), axial T2-weighted (b), and sagittal T2-weighted (c) images of the reconstructed breast show enlarged level I and II axillary lymph nodes (arrows). Biopsy of the axillary nodes revealed moderately differentiated infiltrating ductal carcinoma. m in a = pectoralis muscle.

View larger version (135K): [in a new window]   Figure 9b.  Nodal recurrence in a 50-year-old woman with an axillary mass after TRAM flap reconstruction. Axial T1-weighted (a), axial T2-weighted (b), and sagittal T2-weighted (c) images of the reconstructed breast show enlarged level I and II axillary lymph nodes (arrows). Biopsy of the axillary nodes revealed moderately differentiated infiltrating ductal carcinoma. m in a = pectoralis muscle.

View larger version (185K): [in a new window]   Figure 9c.  Nodal recurrence in a 50-year-old woman with an axillary mass after TRAM flap reconstruction. Axial T1-weighted (a), axial T2-weighted (b), and sagittal T2-weighted (c) images of the reconstructed breast show enlarged level I and II axillary lymph nodes (arrows). Biopsy of the axillary nodes revealed moderately differentiated infiltrating ductal carcinoma. m in a = pectoralis muscle.

View larger version (88K): [in a new window]   Figure 10a.  Delayed recurrence in a 51-year-old woman with a chest wall mass 10 years after mastectomy and TRAM flap reconstruction. (a, b) Sagittal T1-weighted (a) and unenhanced 3D fat-saturated GRE T1-weighted (b) images of the reconstructed breast show a spiculated lesion in the inframammary crease. (c) Sagittal gadolinium-enhanced 3D fat-saturated GRE T1-weighted image shows avid enhancement of the lesion.

View larger version (116K): [in a new window]   Figure 10b.  Delayed recurrence in a 51-year-old woman with a chest wall mass 10 years after mastectomy and TRAM flap reconstruction. (a, b) Sagittal T1-weighted (a) and unenhanced 3D fat-saturated GRE T1-weighted (b) images of the reconstructed breast show a spiculated lesion in the inframammary crease. (c) Sagittal gadolinium-enhanced 3D fat-saturated GRE T1-weighted image shows avid enhancement of the lesion.

View larger version (103K): [in a new window]   Figure 10c.  Delayed recurrence in a 51-year-old woman with a chest wall mass 10 years after mastectomy and TRAM flap reconstruction. (a, b) Sagittal T1-weighted (a) and unenhanced 3D fat-saturated GRE T1-weighted (b) images of the reconstructed breast show a spiculated lesion in the inframammary crease. (c) Sagittal gadolinium-enhanced 3D fat-saturated GRE T1-weighted image shows avid enhancement of the lesion.