Cutaneous recurrence post mastectomy and breast reconstruction

Case contributed by Dr. Chris O'Donnell


Cutaneous mass in skin wound post mastectomy and TRAM (Transverse Rectus Abdominis Myocutaneous) flap breast reconstruction. MRI for further assessment.

Patient Data

Age: 60
Gender: Female

Small nodule in the left breast skin adjacent to the nipple showing marked restriction of diffusion (b value 800) and plateau contrast enhancement (green). Note fatty replacement of breast tissue by the TRAM flap. The patient has had subcutaneous mastectomy with removal of tumor and remaining breast tissue and immediate (rather than delayed) TRAM flap reconstruction to fill the defect. Tumor has recurred in the skin. Note susceptibility artefact from surgical clips.

Case Discussion

There are medical and psychological reasons that need to be taken into account regarding the timing of breast reconstruction post mastectomy for breast cancer. It is generally well accepted that radiation negatively influences the outcome of implant-based breast reconstruction. However, the long-term effect of radiation therapy on the outcome of breast reconstruction with the free transverse rectus abdominis myocutaneous (TRAM) flap is still unclear. For patients who need post mastectomy radiation therapy, the optimal timing of TRAM flap reconstruction is controversial.

Early complications of radiation therapy can include vessel thrombosis with partial or total flap loss, mastectomy skin flap necrosis, and local wound-healing problems whereas late complications included fat necrosis, volume loss, and flap contracture of free TRAM breast mounds.

It is now believed that TRAM flap reconstruction should probably be delayed till after radiotherapy has been completed in order to reduce complications whereas patient psychology often dictates that reconstruction be performed immediately.

There does not seem to be an increased risk of local cancer recurrence in women who have TRAM flap reconstruction compared to those who have no reconstruction.

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