imaging of breast implants m.sklair-levy, m.d radiology department sheba medical center israel

IMAGING OF BREAST IMAGING OF BREAST IMPLANTSIMPLANTS

M.Sklair-Levy, M.DM.Sklair-Levy, M.DRadiology Department Radiology Department Sheba Medical CenterSheba Medical Center

IsraelIsrael

Imaging the Breasts in Patients with Imaging the Breasts in Patients with Breast ImplantsBreast Implants

The goal of imagingThe goal of imaging: :

To evaluate breast tissues To evaluate breast tissues

To evaluate the implants for To evaluate the implants for complicationscomplications

BackgroundBackground

Breast augmentation has been performed Breast augmentation has been performed for more than a centuryfor more than a century

Different substances have been used: Different substances have been used: – FatFat from lipomas - from lipomas - 18951895 - - CzernyCzerny – ParaffinParaffin - - 1904 1904

– Polyvinyl alcohol Polyvinyl alcohol plastic spongesplastic sponges - - 1940 1940

– Free siliconeFree silicone injections - injections - 1945 1945


Associated with unacceptably Associated with unacceptably high high complication ratescomplication rates– InflammationInflammation– Granuloma formationGranuloma formation– NecrosisNecrosis– Hardening and deformity of the breastHardening and deformity of the breast– Migration of the implanted Migration of the implanted

materials,embolization and death. materials,embolization and death.


1962 - The Cronin implant - 1962 - The Cronin implant - the the modern silicone gel-filled implantmodern silicone gel-filled implant

– Outer silicone elastomer Outer silicone elastomer membrane - shellmembrane - shell

– Filled with silicone gelFilled with silicone gel


In In 19921992 the FDA limited the use of the FDA limited the use of

silicone implants silicone implants

– Concern about the safety of silicone Concern about the safety of silicone

implantsimplants

Only Only saline-filled implantssaline-filled implants have been have been

available for available for cosmeticcosmetic augmentationaugmentation


CurrentCurrent scientific data does not scientific data does not demonstrate an association betweendemonstrate an association between

breast implants and various diseasesbreast implants and various diseasesThe greatest concern was that implants may The greatest concern was that implants may stimulate stimulate – Autoimmune reactionsAutoimmune reactions – Rheumatoid syndromesRheumatoid syndromes

Introduction Introduction

FDAFDA recommended recommended removalremoval of ruptured of ruptured implants implants

Led to the demand for accurate diagnosis Led to the demand for accurate diagnosis – Clinical diagnosis Clinical diagnosis ; ; breast sizebreast size or or consistencyconsistency – misses 50%misses 50% of ruptures Implant of ruptures Implant

Accurate diagnostic imagingAccurate diagnostic imaging

Introduction Introduction

Since 1962 - estimated 1.5 to 2 million Since 1962 - estimated 1.5 to 2 million women have had placement of breast women have had placement of breast implantsimplants

– 80%80% - placed for breast augmentation - placed for breast augmentation

– 20%20% - for breast reconstruction following - for breast reconstruction following mastectomy mastectomy

Types of ImplantsTypes of Implants

There are numerous types of implantsThere are numerous types of implants More than 200 different typesMore than 200 different types

The most common types:The most common types: Single-lumen salineSingle-lumen saline

Single-lumen silicone Single-lumen silicone

Double-lumen implantsDouble-lumen implants

Single-Lumen Saline ImplantsSingle-Lumen Saline Implants

Outer silicone envelopeOuter silicone envelope filled with filled with salinesaline – Various valvesVarious valves in the envelope for filling or in the envelope for filling or

positioningpositioningmay be palpable and mistaken for a massmay be palpable and mistaken for a mass

may also be evident by mammographymay also be evident by mammography

The type most frequently implanted today The type most frequently implanted today in the USA in the USA

Disadvantages Disadvantages

Less optimal cosmeticLess optimal cosmetic result than does result than does silicone gel silicone gel

More prone to ruptureMore prone to rupture with minor trauma with minor trauma – the saline is almost always rapidly resorbed the saline is almost always rapidly resorbed

Single-Lumen Saline Implants Single-Lumen Saline Implants

Single-Lumen Saline Implants Single-Lumen Saline Implants

Double-lumenDouble-lumen ImplantsImplants

Double-Lumen (Bilumen) Implants Double-Lumen (Bilumen) Implants

Inner silicone gel compartmentInner silicone gel compartment

Outer saline compartmentOuter saline compartment

Silicone elastomer membrane surrounds Silicone elastomer membrane surrounds each compartmenteach compartment– fill valve fill valve – degree of filling variesdegree of filling varies

Reverse double-lumen ImplantsReverse double-lumen Implants

Double-lumen Double-lumen expander implantsexpander implants ( (Becker Becker implantsimplants) ) – Inner saline compartment Inner saline compartment – Outer silicone gel compartment Outer silicone gel compartment

Silicone elastomer membrane surrounds Silicone elastomer membrane surrounds each compartment each compartment Most often used for Most often used for breast reconstruction breast reconstruction after mastectomyafter mastectomy – Size adjustabilitySize adjustability

IMAGINGIMAGING

MammographyMammography

Conventional MLO , CC viewsConventional MLO , CC views

Implant displacement views Implant displacement views

Spot-compression and magnification Spot-compression and magnification views are possible views are possible

Conventional MammographyConventional Mammography

Standard viewsStandard views - MLO and CC - MLO and CC – the implants in the field of view the implants in the field of view – compression sufficient to hold the breastcompression sufficient to hold the breast

Rupture of implants during mammography Rupture of implants during mammography is rare but has been reportedis rare but has been reported


Implant displacement viewsImplant displacement views - MLO, CC - MLO, CC

– Improve the ability to image the breast tissues Improve the ability to image the breast tissues

Displacing the implant back against the Displacing the implant back against the chest wall chest wall Breast tissues pulled forward as with a Breast tissues pulled forward as with a normal mammogramnormal mammogram

– Direct compression applied separating Direct compression applied separating overlapping structuresoverlapping structures

Positioning of the implantsPositioning of the implants

The implantation site – subglandular subglandular

– retropectoralretropectoral

Subglandular Position

Mainly in the Mainly in the pastpast

– The implant The implant is placed is placed behind the behind the breast breast tissue tissue

– In front of In front of the the pectoralis pectoralis major major musclemuscle

Subpectoral PlacementSubpectoral Placement Behind the pectoralis major muscleBehind the pectoralis major muscle

Mammography – Type of ImplantMammography – Type of Implant

The The type of implanttype of implant can usually be can usually be determined determined

Possible to distinguish between Possible to distinguish between saline and saline and silicone gel single-lumensilicone gel single-lumen implants implants

Mammography - Type of ImplantMammography - Type of Implant

single-lumen silicone gel implant single-lumen

saline implant

double-lumen implant

Bulges, irregularitiesBulges, irregularities, in the outer contour , in the outer contour of silicone implants are of silicone implants are nonspecificnonspecific– Likely due to pressure deformity from the Likely due to pressure deformity from the

surrounding tissuessurrounding tissues– Incomplete fibrous encapsulationIncomplete fibrous encapsulation

Herniation -Herniation - protrusion of the implant through protrusion of the implant through opening in the fibrous capsuleopening in the fibrous capsule

Mammography of Intact ImplantsMammography of Intact Implants

Focal or diffuse calcifications may be seen along Focal or diffuse calcifications may be seen along the surface of the implant the surface of the implant

Tend to Tend to increase with the ageincrease with the age of the implant of the implant – probably due to microscopic gel bleed through the probably due to microscopic gel bleed through the

capsulecapsule

Do not indicate ruptureDo not indicate rupture of the implant of the implant

No clinical significance No clinical significance

Capsular Calcifications Capsular Calcifications

Capsular CalcificationsCapsular Calcifications

As expected with other surgical procedure As expected with other surgical procedure in which a prosthetic device is implantedin which a prosthetic device is implanted

– Acute Acute

– LateLate

Complications of Breast ImplantsComplications of Breast Implants

Bleeding and infectionBleeding and infection

AsymmetryAsymmetry

Loss of nipple sensationLoss of nipple sensation

Pain and tendernessPain and tenderness

Acute Complications Acute Complications

AsymmetryAsymmetry - - implants can be asymmetric implants can be asymmetric in size, shape, or position. in size, shape, or position. – AdvantageAdvantage of of salinesaline and and double-lumen double-lumen

implants is that the implants is that the sizesize can be can be adjusted adjusted

Loss of Nipple SensationLoss of Nipple Sensation– Occurs most frequently with the periareolar Occurs most frequently with the periareolar

approachapproach

Acute ComplicationsAcute Complications

Capsular contractureCapsular contracture

Rupture (intracapsular or extracapsular)Rupture (intracapsular or extracapsular)

MigrationMigration

HerniationHerniation

Hematoma/seromaHematoma/seroma

InfectionInfection

Late - Complications Late - Complications

Most common complicationMost common complication– Occurs in 10%Occurs in 10%– Capsule formation begins within weeks of Capsule formation begins within weeks of

implantationimplantationAll implants become encapsulated by All implants become encapsulated by fibrous tissuefibrous tissue

– A response to A response to foreign bodyforeign body

– Contraction can occur Contraction can occur weeks to yearsweeks to years after after implantationimplantation

Capsular Contracture Capsular Contracture

The exact cause of capsular contracture is The exact cause of capsular contracture is uncertainuncertain– Gel bleedGel bleed - silicone - silicone gel leakagegel leakage through through

microperforations in an microperforations in an intact implantintact implant envelopeenvelope

Stimulate production of collagen around the Stimulate production of collagen around the implantimplant

Leading to fibrous capsule formation and Leading to fibrous capsule formation and capsular contracturecapsular contracture

Capsular ContractureCapsular Contracture

Implant RuptureImplant Rupture

The The second most common complication second most common complication Loss of integrity of the implant envelope/shellLoss of integrity of the implant envelope/shell

– Most implants show some evidence of implant Most implants show some evidence of implant

leakage after leakage after 15 years 15 years

SpectrumSpectrum of ruptures ranging from of ruptures ranging from microscopicmicroscopic

rents to rents to complete collapsecomplete collapse of the implant of the implant

IncidenceIncidence

The The absolute incidenceabsolute incidence and prevalence of and prevalence of implant rupture is implant rupture is not knownnot known

The reported incidence variesThe reported incidence varies

– 5% -10%5% -10% - initial studies - in - initial studies - in asymptomaticasymptomatic patientspatients based on clinical and based on clinical and mammography mammography

– 34% - MRI studies34% - MRI studies

SymptomsSymptoms

SymptomsSymptoms - depending on the type of implant - depending on the type of implant

Ruptured salineRuptured saline implants implants deflate rapidlydeflate rapidly

Rupture of single-lumen Rupture of single-lumen silicone gel implantssilicone gel implants or or of double-lumen implants - of double-lumen implants - more difficult to more difficult to evaluate evaluate

Single-Lumen Saline ImplantSingle-Lumen Saline Implant

Complete collapseComplete collapse of the implant and its capsule of the implant and its capsule almost almost immediatelyimmediately after rupture after rupture– Marked asymmetryMarked asymmetry of the breasts of the breasts

Diagnostic imagingDiagnostic imaging - - unnecessaryunnecessary – Clinical findings enough Clinical findings enough – Imaging to rule out breast pathologyImaging to rule out breast pathology

Single Lumen Saline Implant Rupture

Saline Implant RuptureSaline Implant Rupture

Intact saline implant Collapsed saline implant

Silicone Gel Implant RuptureSilicone Gel Implant Rupture

Intracapsular ruptureIntracapsular rupture – – most commonmost commonRupture of the shellRupture of the shell , silicone gel that leaks out of , silicone gel that leaks out of the implant remains confined within the periimplant the implant remains confined within the periimplant fibrous capsule fibrous capsule

Extracapsular ruptureExtracapsular rupture - implant envelope - implant envelope rupture with silicone gel extruded outside rupture with silicone gel extruded outside of the fibrous capsule of the fibrous capsule

Implants Shell / Fibrous CapsuleImplants Shell / Fibrous Capsule

SymptomsSymptoms

The clinical findings - The clinical findings - difficult to evaluatedifficult to evaluate– can be clinically inapparent can be clinically inapparent

The implant can remain almost fully expanded The implant can remain almost fully expanded – even in complete collapse even in complete collapse – the outer contour of the periimplant capsule can the outer contour of the periimplant capsule can

remain normalremain normal– the breast size will appear normalthe breast size will appear normal

Mammography of Silicone Gel Implant Mammography of Silicone Gel Implant RuptureRupture

Extracapsular ruptureExtracapsular rupture Irregular collections of free silicone outside Irregular collections of free silicone outside thethe implant – implant – unusualunusual

Silicone in Silicone in axillary lymph nodes axillary lymph nodes

Contour abnormalities – more common - Contour abnormalities – more common - may be misleadingmay be misleading

cannot be differentiated from herniationcannot be differentiated from herniation

Implant BulgeImplant Bulge

Extracapsular ruptureExtracapsular rupture

Mammography - Intracapsular RuptureMammography - Intracapsular RuptureLow SensitivityLow Sensitivity

Imaging After ExplantationImaging After Explantation

Residual silicone Residual silicone

Residual fibrous capsuleResidual fibrous capsule and and calcificationscalcifications

– Explantation through a capsulotomy Explantation through a capsulotomy

– Capsulectomy in addition to explantationCapsulectomy in addition to explantation

Imaging After ExplantationImaging After Explantation

Residual fibrous capsule Residual silicone

ULTRASOUNDULTRASOUND

The same supine or obliqueThe same supine or oblique position position

Linear transducer - Linear transducer - 7- 12-MHz7- 12-MHz

Large implantsLarge implants or or severe contracturesevere contracture -- 5-MHz 5-MHz linearlinear or even curved linear transducers or even curved linear transducers

Light compression during scanning Light compression during scanning

Technique Technique

Echogenicity of Implant Contents

Intact silicone & saline implants are Intact silicone & saline implants are anechoicanechoic

Reverberation Artifact

Reverberation echoes Reverberation echoes in the near field in the near field

not uncommonnot uncommon

Must be distinguished Must be distinguished from the echogenicityfrom the echogenicity

Light compression- Light compression- minimize reverberation minimize reverberation echoesechoes

Reverberation Artifacts

Normal variantsNormal variants – May be palpable – when occur on the anterior May be palpable – when occur on the anterior

surface surface

– Dynamic - not fixed in position and size Dynamic - not fixed in position and size

Radial Folds Radial Folds

Radial FoldRadial Fold

Saline implants, expanders, and certain Saline implants, expanders, and certain

double-lumen implants have fill valvesdouble-lumen implants have fill valves

– can be palpable can be palpable

Implant Fill Valves Implant Fill Valves

Fill Valve - Single-Lumen Saline Implant

Periimplant Effusions

Implantation Site

Subglandular implant Retropectoral implant

US of Implant RuptureUS of Implant Rupture

ExtracapsularExtracapsular Rupture Rupture

Snow stormSnow storm appearance - The appearance - The classic classic sonographic description ofsonographic description of extravasatedextravasated silicone silicone

– Homogeneous hyperechoic noise/nodule Homogeneous hyperechoic noise/nodule

– Posterior shadowingPosterior shadowing

Snowstorm AppearanceSnowstorm Appearance

Extracapsular SiliconeExtracapsular Silicone

There is a There is a spectrum of sonographic spectrum of sonographic appearancesappearances of silicone granulomas of silicone granulomas

– sizesize

– chronicity chronicity

Final diagnosis - biopsyFinal diagnosis - biopsy

Complex Cystic NodulesComplex Cystic NodulesAcute ExtravasationAcute Extravasation

Isoechoic Nodule Isoechoic Nodule Silicone Granulomas of Intermediate AgeSilicone Granulomas of Intermediate Age

Acoustic Shadowing Acoustic Shadowing Old Silicone GranulomasOld Silicone Granulomas

Silicone in Lymph NodesSilicone in Lymph Nodes

May be associated with extracapsular May be associated with extracapsular rupturerupture

Appear Appear hyperechoichyperechoic– beginning in the beginning in the hilum hilum – progressing to the progressing to the cortexcortex

snowstorm shadowing snowstorm shadowing

Silicone in Lymph NodesSilicone in Lymph Nodes

Intracapsular RuptureIntracapsular Rupture

Stepladder SignStepladder Sign - - multiple folds of the multiple folds of the collapsed implant shell floating within a collapsed implant shell floating within a extravasated silicone gel extravasated silicone gel

– Occurs in Occurs in large rupturelarge rupture with with complete or complete or nearly complete collapsenearly complete collapse

Stepladder SignStepladder Sign

Ultrasound & Intracapsular ruptureUltrasound & Intracapsular rupture

There is a spectrum of intracapsular There is a spectrum of intracapsular

rupture that varies:rupture that varies:

– size of rupturesize of rupture

– the degree of the degree of collapsecollapse

Increased Echogenicity

Intact implantIntracapsular rupture

Separation between the Capsule and Shell

Intact implant

3 echogenic lines

Intracapsular rupture

1 echogenic line

US of Double-Lumen Implants RuptureUS of Double-Lumen Implants Rupture

More difficult to evaluate ruptureMore difficult to evaluate rupture

Extracapsular rupture of outer saline shellExtracapsular rupture of outer saline shell– may simulate may simulate single-lumen silicone gelsingle-lumen silicone gel

implantsimplants

Intracapsular ruptureIntracapsular rupture - mixing of saline and - mixing of saline and silicone gel components silicone gel components – a mottling of echogenicity, simulating a mottling of echogenicity, simulating

intracapsular rupture of single-lumen silicone intracapsular rupture of single-lumen silicone gel implants gel implants

MRIMRI

TechniqueTechnique

MRI exams - 1.5T MRI exams - 1.5T

In prone position In prone position

Phased-array breast surface coilPhased-array breast surface coil

Scan parameters Scan parameters – High-resolutionHigh-resolution T2-weighted water/silicone T2-weighted water/silicone

suppressedsuppressed– T1W fat suppressedT1W fat suppressed

No I.V. contrastNo I.V. contrast

Total scan time - 45min.Total scan time - 45min.

MR Appearance of Normal ImplantsMR Appearance of Normal Implants

The locationThe location - subpectoral or subglandular - subpectoral or subglandular

Radial Folds Radial Folds

Radial foldsRadial folds - - infoldings of redundant envelope infoldings of redundant envelope

– Low signal intensityLow signal intensity linear bands extending linear bands extending

from the periphery of the implant into the gel from the periphery of the implant into the gel

or saline as undulations of the implant or saline as undulations of the implant

contourcontour

Radial FoldsRadial Folds

Complex Radial Folds - Long CurvedComplex Radial Folds - Long Curved

http://radiographics.rsnajnls.org/cgi/content/full/20/3/e1/F50

MRI of Ruptured ImplantMRI of Ruptured Implant

Intracapsular ruptureIntracapsular rupture

Extracapsular ruptureExtracapsular rupture


Linguine sign-Linguine sign- Ruptured envelope Ruptured envelope

floating within the silicone gel floating within the silicone gel

– Sensitivity - 76% to 94% Sensitivity - 76% to 94% – Specificity - 97% to 100%Specificity - 97% to 100%– Accuracy - 92%Accuracy - 92%– PPV - 99% ; NPV - 79% PPV - 99% ; NPV - 79%

Linguine SignLinguine Sign


Intracapsular ruptureLinguine sign- complete collapse

Subcapsular LineSubcapsular Line

local shell displacement

Keyhole Sign - Keyhole Sign - silicone within a short radial silicone within a short radial foldfold

Subcapsular lineSubcapsular line

Mottled AppearanceMottled Appearance

Extracapsular RuptureExtracapsular Rupture

The fibrous capsule and the shell are both The fibrous capsule and the shell are both rupturedruptured

DiagnosisDiagnosis - silicone outside of the fibrous - silicone outside of the fibrous capsulecapsule– breast parenchyma breast parenchyma – Axillary lymph nodes Axillary lymph nodes


Intra &extra ruptureSilicon in axillary lymph nodes

Extracapsular rupture; intracapsular rupture not seen

MRI - Double Lumen ImplantsMRI - Double Lumen Implants

Can be difficult to evaluate,especially Can be difficult to evaluate,especially

when implant type is unknown when implant type is unknown

MRI - Double Lumen ImplantsMRI - Double Lumen Implants

Extracapsular ruptureExtracapsular rupture - - leakleak of the of the water water from the from the outer compartmentouter compartment– CanCan completely completely mimicmimic an intact an intact single lumen single lumen

silicon implant silicon implant

Intracapsular ruptureIntracapsular rupture - rupture of the - rupture of the inner inner membrane – membrane – – Mixing of water and gel Mixing of water and gel

Reverse Double Lumen- Becker expender

salinesaline

Implants and Breast CancerImplants and Breast Cancer

There is no evidence that implants cause There is no evidence that implants cause breast cancerbreast cancer – Breast implants interfere with performance Breast implants interfere with performance

and interpretation of screening mammographyand interpretation of screening mammography– Delayed detectionDelayed detection of breast cancer of breast cancer

US , MRI can be usefulUS , MRI can be useful– Contrast enhanced sequence addedContrast enhanced sequence added

SummarySummary

MammographyMammography - - extracapsular ruptureextracapsular rupture

– Insensitive for intracapsular ruptureInsensitive for intracapsular rupture

UltrasoundUltrasound – – extracapsular rupture extracapsular rupture

– Intracapsular rupture Intracapsular rupture

MRIMRI – Advantages - Sensitivity 94% ; Specificity Advantages - Sensitivity 94% ; Specificity

97%97%– Disadvantage - most expensive, less Disadvantage - most expensive, less

availableavailable


Focal or diffuse calcifications may be seen along Focal or diffuse calcifications may be seen along the surface of the implant the surface of the implant

Tend to Tend to increase with the ageincrease with the age of the implant of the implant – probably due to microscopic gel bleed through the probably due to microscopic gel bleed through the

capsulecapsule

Do not indicate ruptureDo not indicate rupture of the implant of the implant

No clinical significance No clinical significance


Bleeding and InfectionBleeding and Infection

The risk for bleeding and infection is The risk for bleeding and infection is similar to the risks of any surgerysimilar to the risks of any surgery

InfectionInfection occurring in the acute phase may occurring in the acute phase may persist until the implant is removedpersist until the implant is removed


AsymmetryAsymmetry - - implants can be asymmetric implants can be asymmetric in size, shape, or position. in size, shape, or position. – AdvantageAdvantage of of salinesaline and and double-lumen double-lumen

implants is that the implants is that the sizesize can be can be adjusted adjusted

Loss of Nipple SensationLoss of Nipple Sensation– Occurs most frequently with the periareolar Occurs most frequently with the periareolar

approachapproach


Most common complicationMost common complication– Occurs in 10%Occurs in 10%– Capsule formation begins within weeks of Capsule formation begins within weeks of

implantationimplantation

All implants become encapsulated by fibrous All implants become encapsulated by fibrous tissuetissue

– A response to A response to foreign bodyforeign body

– Contraction can occur Contraction can occur weeks to yearsweeks to years after after implantationimplantation


The exact cause of capsular contracture is The exact cause of capsular contracture is uncertainuncertain– Gel bleedGel bleed - silicone - silicone gel leakagegel leakage through through

microperforations in an microperforations in an intact implantintact implant envelopeenvelope

Stimulate production of collagen around the Stimulate production of collagen around the implantimplant

Leading to fibrous capsule formation and Leading to fibrous capsule formation and capsular contracturecapsular contracture

The Baker ScoreThe Baker Score

• A standardized scoring systemA standardized scoring system• Clinically evaluates the breast’s Clinically evaluates the breast’s

appearance, texture, and tendernessappearance, texture, and tenderness• 4 grades of severity, ranging from 4 grades of severity, ranging from

normal to deformednormal to deformed

• American Society of Plastic Surgeons: Silicone breast implant surgery. www.plasticsurgery.org/public_education/silicone-breast-implant-surgery.cfm • Holmes JD: Capsular contracture after breast reconstruction with tissue expansion. Br J Plast Surg 1989 • O’Toole M, Caskey CI: Imaging spectrum of breast implant complications: mammography, ultrasound, and magnetic resonance imaging. Semin Ultrasound CT MR 2000

http://www.plasticsurgery.org/public_education/silicone-breast-implant-surgery.cfm

TreatmentTreatment

Implant – Implant – various textures, shapes, and various textures, shapes, and locationslocations– Changing the Changing the site of implantationsite of implantation from sub- from sub-

glandular to glandular to retropectoralretropectoral

Saline implantsSaline implantsDouble - lumen implantsDouble - lumen implantsClosed or open capsulotomyClosed or open capsulotomy

• Capsule removalCapsule removal• Implant revision and replacementImplant revision and replacement

US & Capsular ContractionUS & Capsular Contraction

The The diagnosisdiagnosis is made is made clinicallyclinically

The sonographic findings include The sonographic findings include – AbnormalAbnormal spherical shape spherical shape– The capsule The capsule is is thickenedthickened > 1.5 mm> 1.5 mm

– The number of The number of radial foldsradial folds increases increasesredundancy of the shellredundancy of the shell

Capsular ContractionCapsular Contraction

Normal implant

Contracted spherical implant

Capsular ContractionCapsular Contraction

1mm 3.5mm


Disadvantages Disadvantages

Less optimal cosmeticLess optimal cosmetic result than does result than does silicone gel silicone gel

More prone to ruptureMore prone to rupture with minor trauma with minor trauma – the saline is almost always rapidly resorbed the saline is almost always rapidly resorbed


Bleeding and infectionBleeding and infection

AsymmetryAsymmetry

Loss of nipple sensationLoss of nipple sensation

Pain and tendernessPain and tenderness

Diagnosis of Implant Rupture Diagnosis of Implant Rupture

Mammography Mammography

UltrasoundUltrasound

MRI MRI

Mammography & Implant RuptureMammography & Implant Rupture

The sensitivity depends upon: The sensitivity depends upon:

– Type of implant – saline , silicone gel implantType of implant – saline , silicone gel implant

– Type of rupture – intracapsular , extracapsularType of rupture – intracapsular , extracapsular

Single Lumen Saline Implant RuptureSingle Lumen Saline Implant Rupture

Rupture of Rupture of single lumen saline implantssingle lumen saline implants is is

usually both clinically and usually both clinically and

mammographically obvious mammographically obvious

Technique Technique

The same supine or obliqueThe same supine or oblique position position

Linear transducer - Linear transducer - 7- 12-MHz7- 12-MHz

Large implantsLarge implants or or severe contracturesevere contracture -- 5-MHz 5-MHz linearlinear or even curved linear transducers or even curved linear transducers

Light compression during scanning Light compression during scanning

Radial FoldsRadial Folds

Normal variantsNormal variants – May be palpable – when occur on the anterior May be palpable – when occur on the anterior

surface surface

– Dynamic - not fixed in position and size Dynamic - not fixed in position and size

Radial FoldRadial Fold

Implant Fill ValvesImplant Fill Valves

Saline implants, expanders, and certain Saline implants, expanders, and certain

double-lumen implants have fill valvesdouble-lumen implants have fill valves

– can be palpable can be palpable

Fill Valve - Single-Lumen Saline ImplantFill Valve - Single-Lumen Saline Implant

MRI ProtocolMRI Protocol

– Axial T1-Axial T1-weighted GRE weighted GRE localizerlocalizer

– SagitalSagital / / Axial T2Axial T2 W- W- FSE FSE water-water-suppressedsuppressed

– Axial/Sag T1WAxial/Sag T1W silicon suppressedsilicon suppressed


Breast cancer detectionBreast cancer detection - - sensitivity is sensitivity is reducedreduced

– Radiopaque - obscuring large volumes of Radiopaque - obscuring large volumes of

breast tissue breast tissue

Evaluation of implant integrityEvaluation of implant integrity

Mammography - Implant Location Mammography - Implant Location

Seen on MLO viewsSeen on MLO views– sometimes possible on CC views sometimes possible on CC views

Complications of Breast ImplantsComplications of Breast Implants

As expected with other surgical procedure As expected with other surgical procedure in which a prosthetic device is implantedin which a prosthetic device is implanted

– Acute Acute

– LateLate

Late - ComplicationsLate - Complications

Capsular contractureCapsular contracture

Rupture (intracapsular or extracapsular)Rupture (intracapsular or extracapsular)

MigrationMigration

HerniationHerniation

Hematoma/seromaHematoma/seroma

InfectionInfection

Mammography of Intact ImplantsMammography of Intact Implants

Bulges, irregularitiesBulges, irregularities, in the outer contour , in the outer contour of silicone implants are of silicone implants are nonspecificnonspecific– Likely due to pressure deformity from the Likely due to pressure deformity from the

surrounding tissuessurrounding tissues– Incomplete fibrous encapsulationIncomplete fibrous encapsulation

Herniation -Herniation - protrusion of the implant through protrusion of the implant through opening in the fibrous capsuleopening in the fibrous capsule

Implant Type Implant Type

Difference in the speed of sound – Difference in the speed of sound – – Slower through silicone gel - 997 m/s Slower through silicone gel - 997 m/s – Soft tissues - 1,540 m/s through Soft tissues - 1,540 m/s through

In silicone implantsIn silicone implants - there will be a - there will be a step-offstep-off in in the chest wall at the edge of the implant the chest wall at the edge of the implant – the the chest wall will appear deeperchest wall will appear deeper behind the implant behind the implant

In saline implantsIn saline implants - there - there is no step-offis no step-off in the in the chest wall chest wall

US of Silicone & Saline ImplantsUS of Silicone & Saline Implants

Saline implant

Chest wall

No step off

Silicon implant

Chest wall-step off

Periimplant EffusionsPeriimplant Effusions

Implantation SiteImplantation Site

Subglandular implant Retropectoral implant

US of ComplicationsUS of Complications

Capsule – Shell ComplexCapsule – Shell Complex

1. Outer surface of capsule

2. Middle line –merged echo of inner surface capsule and outer surface of shell;

• the space between - the thickness of the capsule

3. Posterior line-inner surface of the shell

silicon

capsule

shell


Subcapsular LineSubcapsular Line - - local shell displacement local shell displacement

Teardrop or keyhole signTeardrop or keyhole sign -- silicone within a silicone within a short radial foldshort radial fold– Lees sensitiveLees sensitive– Sensitivity increases if seen in more than one Sensitivity increases if seen in more than one

picture and in two planespicture and in two planes

Mottled appearanceMottled appearance of the silicone within the of the silicone within the implantimplant

Double Lumen ImplantDouble Lumen Implant

Reverse Double Lumen - Becker ExpenderReverse Double Lumen - Becker Expender

Reverse Double LumenReverse Double Lumen

US of Implant RuptureUS of Implant Rupture

Silicone gel single lumen implantsSilicone gel single lumen implants

Complex implantsComplex implants

– Intracapsular rupture Intracapsular rupture

– Extracapsular ruptureExtracapsular rupture

Reverberation ArtifactReverberation Artifact

Reverberation echoesReverberation echoes in in the near field the near field

not uncommonnot uncommon

Must be distinguished Must be distinguished from the from the echogenicityechogenicity

Light compression- Light compression- minimize reverberation minimize reverberation echoesechoes

Reverberation ArtifactsReverberation Artifacts

Imaging of Breast ImplantsImaging of Breast Implants

Implants composed of :Implants composed of :

Inner compartmentInner compartment – silicone , saline – silicone , saline

Outer membraneOuter membrane – – – Shell (silicone elastomer membraneShell (silicone elastomer membrane) – part of ) – part of

the implantthe implant– Fibrous CapsuleFibrous Capsule – – not part of the implantnot part of the implant

is the body’s response to the implantis the body’s response to the implant

imaging of breast implants m.sklair-levy, m.d radiology department sheba medical center israel

Documents

silicone gel slide

imaging of breast implants

safety of silicone implants

placement of breast

possible slide

mastectomy slide

usa slide

numerous types of implants