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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_5791_Библиотеки_им_академика_М_И_Перельмана.pdf
232
Fig. 11.1 Status after
radical breast resection.
Lymphostasis. Sonograms.
Gray scale and panoramic
scan
11 Ultrasound Examination After Breast Surgery
and/or in interfascial spaces. It leads to seroma.
If the volume of fl uid collections is large and
accompanied by fever or general inconvenience,
US-guided puncture may be performed to aspirate the contents. The increase in echodensity
of the skin and subcutaneous tissues is a consequence of lymphedema (local lymphostasis in
postoperative region) (Fig.
11.1 ).
Excision of a benign tumor or breast tissue suspicious for carcinoma can be done with
sector resection or lumpectomy. It is a method
of choice in masses suspicious for breast carcinoma to verify the diagnosis and in benign
lesions ( fi broadenoma, lipoma, granuloma,
chronic mastitis, etc.). US is usually performed
in postoperative period to detect breast
hematoma.
Hematoma is observed as an anechoic or
hypoechoic lesion of regular (rarely, irregular)
shape with accurate distinct margins and heterogeneous structure. It often contains linear echogenic incorporations and septations. CDI, PDI,
and 3DPD detect no blood vessels (Fig. 11.2 ).
Signi fi cant blood collections demand
US-guided puncture with fl uid evacuation, drainage, or repeated surgery for safe hemostasis.
Total biopsy of the tumor is an excision of the
only breast lesion without surrounding tissues. It
is applied for benign lesions with a capsule or
pseudo-capsule, such as fi broadenoma, lipoma,
23311 Ultrasound Examination After Breast Surgery
Fig. 11.2 Status after lumpectomy. Breast hematoma. Grayscale US
and cyst. A hematoma in breast tissues is also a
possible complication.
Radical mastectomy involves removal of
breast tissue, nipple, areolar complex, variable
amount of skin, pectoralis minor, and/or pectoralis
major, as well as en bloc axillary dissection.
A total (simple) mastectomy removes all breast
tissue, the fascia of pectoralis major, the nipple, and
234
Fig. 11.3 Status after
mastectomy. Breast bed.
Sonograms. Gray scale
and panoramic scan
11 Ultrasound Examination After Breast Surgery
areolar complex. An axillary dissection and the
dissection of pectoral muscles are not done, but
sentinel lymph nodes may be removed (Fig.
11.3 ).
Collections of blood or lymphatic fl uid under the
skin may appear in the fi rst few days after surgery.
Hemimastectomy with lymph node dissection aims to remove one-half of the breast with
adipose tissue of the axillary, subscapular, and
subclavian regions. Pectoralis major and minor
are not removed. The breast bed and the adjacent tissues after surgery often appear diffusely
dense with US, exhibit irregular structure with
echogenic incorporations of various sizes and
shapes (Fig. 11.4 ). By the data of Sinyukova and
Sholokhov ( 2010 ) , local fi brosis is observed in
13 % of all lesions in the region of surgery after
operations for breast carcinoma.
Simple mastectomy, mastectomy with lymph
node dissection, and hemimastectomy with
lymph node dissection are not widely used due to
dif fi culties in complete removal of adipose tissue
with lymph nodes.
23511 Ultrasound Examination After Breast Surgery
Fig. 11.4 Status after mastectomy. Local fi brosis of the breast bed. Sonograms. Gray scale and CDI
236
Fig. 11.5 Status after
mastectomy and breast
reconstruction with a dermal
fat fl ap. ( a ) Breast view.
( b ) Grayscale US
11 Ultrasound Examination After Breast Surgery
a
b
Different types of mastectomies can be accompanied by several complications. The most frequent of them are listed below:
Bleeding in the early postoperative period. •
Abundant lymphorrhea with collection of •
signi fi cant amount of lymphatic fl uid under
the skin. Moderate lymphorrhea is a natural
consequence of mastectomy since excision of
lymph nodes and vessels inevitably leads to
abnormal lymph drainage.
Infectious complications in postoperative •
wound.
Breast reconstruction is the type of surgery
that aims to recover the shape and volume of the
breast after mastectomy, trauma, or other injuries. It can be performed with the use of prosthesis (implant), own tissues of the patient, or their
combination.
Reconstruction of the breast with patient’s own
tissues involves the fl aps of skin, subcutaneous
fat, and muscles, which are moved to the breast
place. Dermal fat fl aps contain adipose tissue, so
the breast after such a reconstruction looks like a
breast with involutive changes (Fig. 11.5 ).
Breast reconstruction with own tissues is a
technically complex operation and has high risk
of complications, such as hematomas, seroma,
aseptic in fl ammation, infection, or necrosis of the
dermal fl ap. Adequate drainage with vacuum systems helps to prevent the complications of early
postoperative period.
Breast prosthesis is usually made of silicone,
hence detected with US as spherical or oval
anechoic lesions with distinct three- or fi ve-layer
capsule (Fig.
11.6 ). The capsule can have smooth
contours, but wavy shape is more characteristic.
23711 Ultrasound Examination After Breast Surgery
Fig. 11.6 Status after breast reconstruction with an implant ( arrows ). Sonograms. Gray scale, CDI, panoramic scan,
3D, and US elastography
238
Fig. 11.6 (continued)
11 Ultrasound Examination After Breast Surgery
Fig. 11.6 (continued)
23911 Ultrasound Examination After Breast Surgery
240
11 Ultrasound Examination After Breast Surgery
Fig. 11.6 (continued)
Fig. 11.7 Status after breast
reconstruction. Gel fragments
within breast structure
( arrows ). Grayscale US
24111 Ultrasound Examination After Breast Surgery
US allows to characterize the locations of
implants (number of gel fragments), size (gel
volume), integrity, structure, uniformity, borders,
and the status of surrounding tissues (Fig. 11.7 ).
It is highly effective in diagnosis of early postoperative complications (up to 6.9 %), such as local
in fl ammatory complications, bleeding, hematomas, and seromas, and late complications (up to
65.3 %) including implant damage (intra- or
extracapsular rupture), pseudotumor, siliconoma,
prosthesis hernia, capsular contractures, irregular
distribution of breast volume, migration, or rotation of the implant ( Shumakova et al. 2011 ) .
Fluid (lymph) collections can be often
observed in the implant’s excavations and the
surrounding tissues. A signi fi cant amount of