Breast reduction surgery is one of the most popular procedures performed by plastic surgeons; based on the current literature, it is safe and does not have a negative impact on identifying breast cancer in women. There are no evidence-based data to confirm the utility of unique screening protocols for women planning to undergo reduction surgery or for those who already had reduction. Women undergoing this surgery should not deviate from the current recommendations of screening mammography in women older than 40 years of average risk. Experienced radiologist can readily distinguish postsurgical imaging findings of rearranged breast parenchyma from malignancy.
Key points
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There are no evidence-based data to confirm the utility of unique screening protocols for women undergoing reduction mammaplasty surgery.
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Postoperative screening mammography does not lead to significantly more imaging or diagnostic interventions when compared with nonoperative controls.
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Parenchymal redistribution occurs in 90% of cases and can be seen at mammography and MRI.
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Fat necrosis is common after breast reduction and usually has an easily identifiable appearance on mammography. In its mature form, it can be seen as an oil cyst, which is a lucent, fat-density round or oval mass on mammogram, often with classic rim calcifications at its periphery.
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MRI and ultrasound features of the postreduction mammaplasty breast parallel some of the mammographic findings commonly seen in mammography.
Introduction
Breast reduction surgery is a safe and popular cosmetic procedure for the treatment of symptoms associated with breast hypertrophy. According to the Cosmetic Surgery National Data Bank published in 2014, a total of 114,170 breast reductions were performed in the United States last year; it currently ranks as the eighth most common cosmetic surgery done in this country.
This surgery’s great popularity is due to its success in treating both the complex psychological and physical sequela associated with this disease process. Although generally this procedure has high patient satisfaction, patients are often concerned about this surgery’s impact on the diagnostic accuracy of postprocedural mammography for routine cancer screenings.
The indications for this particular surgery are clear and defined as a syndrome of persistent neck and shoulder pain, painful shoulder grooving from brassiere straps, and chronic intertriginous rash of the inframammary fold caused by an increase in the volume and weight of breast tissue beyond normal proportions. Breast hypertrophy can be associated with significant fibrous breast parenchyma and increased breast density that already poses a decrease in mammogram sensitivity and specificity as a screening method for malignancy.
Although women undergoing reduction mammaplasty are expected to continue routine radiologic screenings for breast cancer, significant debate exists about the current recommendations for screening in the general population. This lack of clear consensus affects our preoperative counseling to patients seeking reduction mammaplasty.
In this article, the authors review the current recommendations for cancer screening with mammography, common radiologic findings after mammaplasty that may impact false-positive tests leading to increase call back numbers. The authors also examine the impact of postsurgical radiographic changes on recognizing breast cancer in this population.
Preoperative Screening Recommendations
There are no evidence-based data to confirm the utility of unique screening protocols for women undergoing reduction mammaplasty surgery or for those who already have had reduction. For average-risk women in general, annual screening mammography for women 40 years of age and older is recommended by the American Cancer Society, the American College of Surgeons, The American College of Radiology, and the American Congress of Obstetricians and Gynecologists. Among women younger than 40 years, the evidence supports screening mammography only for those who have a high risk for breast cancer. There is a logical appeal to obtaining a presurgical baseline mammogram in patients younger than 40 years to diminish the likelihood of an unanticipated occult cancer being found on pathologic examination of the excised breast tissue. However, the incidence of cancer in this age group is low; there are no robust data to support the efficacy of this approach. It is imperative, of course, for the surgeon to identify concerning aspects of the patients’ history or findings on physical examination in the preoperative setting that would suggest the need for further investigation with diagnostic, rather than screening, imaging evaluation.
Introduction
Breast reduction surgery is a safe and popular cosmetic procedure for the treatment of symptoms associated with breast hypertrophy. According to the Cosmetic Surgery National Data Bank published in 2014, a total of 114,170 breast reductions were performed in the United States last year; it currently ranks as the eighth most common cosmetic surgery done in this country.
This surgery’s great popularity is due to its success in treating both the complex psychological and physical sequela associated with this disease process. Although generally this procedure has high patient satisfaction, patients are often concerned about this surgery’s impact on the diagnostic accuracy of postprocedural mammography for routine cancer screenings.
The indications for this particular surgery are clear and defined as a syndrome of persistent neck and shoulder pain, painful shoulder grooving from brassiere straps, and chronic intertriginous rash of the inframammary fold caused by an increase in the volume and weight of breast tissue beyond normal proportions. Breast hypertrophy can be associated with significant fibrous breast parenchyma and increased breast density that already poses a decrease in mammogram sensitivity and specificity as a screening method for malignancy.
Although women undergoing reduction mammaplasty are expected to continue routine radiologic screenings for breast cancer, significant debate exists about the current recommendations for screening in the general population. This lack of clear consensus affects our preoperative counseling to patients seeking reduction mammaplasty.
In this article, the authors review the current recommendations for cancer screening with mammography, common radiologic findings after mammaplasty that may impact false-positive tests leading to increase call back numbers. The authors also examine the impact of postsurgical radiographic changes on recognizing breast cancer in this population.
Preoperative Screening Recommendations
There are no evidence-based data to confirm the utility of unique screening protocols for women undergoing reduction mammaplasty surgery or for those who already have had reduction. For average-risk women in general, annual screening mammography for women 40 years of age and older is recommended by the American Cancer Society, the American College of Surgeons, The American College of Radiology, and the American Congress of Obstetricians and Gynecologists. Among women younger than 40 years, the evidence supports screening mammography only for those who have a high risk for breast cancer. There is a logical appeal to obtaining a presurgical baseline mammogram in patients younger than 40 years to diminish the likelihood of an unanticipated occult cancer being found on pathologic examination of the excised breast tissue. However, the incidence of cancer in this age group is low; there are no robust data to support the efficacy of this approach. It is imperative, of course, for the surgeon to identify concerning aspects of the patients’ history or findings on physical examination in the preoperative setting that would suggest the need for further investigation with diagnostic, rather than screening, imaging evaluation.
Imaging findings postreduction mammaplasty
Regardless of the exact type of reduction procedure performed, the changes seen on imaging reflect the removal and repositioning of breast tissue and the nipple-areolar complex and any associated resultant scarring. Although the traditional inverted-T scar, or Wise pattern, involves both an inframammary fold incision and a vertical incision, newer vertical scar techniques feature a vertical incision alone. The use of the vertical incision decreases scarring and distortion of the inframammary fold, and it aids in shaping the breast by allowing various techniques for parenchymal rearrangement and pedicle creation.
For the surgically altered breast, some investigators suggest obtaining a mammogram 6 to 12 months after surgery to reestablish baseline findings. However, when compared with a control group of patients who did not undergo surgery, patients who underwent reduction mammaplasty did not have a significant difference in mammographic abnormalities (defined as a Breast Imaging Reporting and Data System category 3, 4, or 5 lesions). Breast reduction mammaplasty changes do not decrease the specificity of the screening mammograms as there was no difference in the rate of recall for women for further assessment. Therefore, the practice of obtaining mammographic imaging outside of routine screening intervals is likely not medically necessary or warranted. Despite the substantial tissue mobilization performed during reduction mammaplasty, postoperative screening mammography does not lead to significantly more imaging or diagnostic interventions when compared with nonoperative controls. Interestingly, these investigators noted a decreased rate of breast cancer in the breast-reduction group, which is in keeping with previous study findings.
Mammography
The common mammographic findings associated with reduction surgery include alteration of breast contour, elevation of the nipple, displacement of breast parenchyma, architectural distortion, skin thickening, fibrotic bands of scar, and fat necrosis.
Parenchymal redistribution occurs in 90% of cases and can be seen at mammography and MRI ( Fig. 1 ). The inverted-T horizontal skin incision is seen at imaging as dermal calcifications, skin thickening, or keloids along the inframammary fold. Placement of scar markers on the skin surface may be helpful to localize these findings as lying within the dermis. Vertically oriented skin thickening related to the vertical skin incision can also be seen at imaging ( Fig. 2 ).
