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Case number:	118
Age:	75
Clinical presentation:	Postmenopausal woman who was a known case of bilateral breast cancer and had undergone right breast-conserving surgery, left MRM, and a reconstruction with rectus abdominis muscle presented for a follow-up mammography.

Mammography:

Breast composition:	ACR category b (there are scattered areas of fibroglandular density)
Mammography features:
‣ Location of the lesion:	Right breast, upper quadrant breast-conserving surgery scar tissue with chemoport in situ
‣ Mass:
• Number:	0
• Size:	No
• Shape:	None
• Margins:	None
• Density:	None
‣ Calcifications:
• Typically benign:	None
• Suspicious:	None
• Distribution:	None
‣ Architectural distortion:	None
‣ Asymmetry:	None
‣ Intramammary node:	None
‣ Skin lesion:	None
‣ Solitary dilated duct:	None
‣ Associated features:	None

Breast composition:	ACR category b (there are scattered areas of fibroglandular density)
Mammography features:
‣ Location of the lesion:	Left breast, MRM status, reconstructed TRAM flap seen
‣ Mass:
• Number:	0
• Size:	No
• Shape:	None
• Margins:	None
• Density:	None
‣ Calcifications:
• Typically benign:	Solitary round calcification focus in upper quadrant of the flap
• Suspicious:	None
• Distribution:	None
‣ Architectural distortion:	None
‣ Asymmetry:	None
‣ Intramammary node:	None
‣ Skin lesion:	None
‣ Solitary dilated duct:	None
‣ Associated features:	None

Ultrasound:

BI-RADS:

BI-RADS Category: 2 (benign)

Case summary:

Postmenopausal woman, a known case of bilateral breast cancer who had undergone right breast-conserving surgery and left MRM with rectus abdominis muscle reconstruction, is on regular follow-up mammography. On imaging, heterogeneously dense breast parenchyma in the right breast and TRAM flap reconstruction of the left breast are seen. A chemoport is seen in situ in the right breast.

Learning points:

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The transverse rectus abdominis muscle (TRAM) lies between the waist and pubic bone. A flap of this skin, fat, and all or part of the underlying rectus abdominis muscle are used to reconstruct the breast. Free TRAM flap: The fat, skin, blood vessels, and muscle are cut from the wall of the lower belly and moved up to the chest to rebuild the breast. The surgeon reattaches the blood vessels of the flap to blood vessels in the chest using microsurgery. There is also a “muscle-sparing” free TRAM flap. Pedicled (or attached) TRAM flap: The fat, skin, blood vessels, and muscle from the lower anterior abdominal wall are moved under the skin up to the chest to rebuild the breast. The blood vessels (the artery and vein) of the flap are left attached to their original blood supply in the abdomen. (The artery and the vein are the “pedicle”.)