♦ Breast implant rupture
: Well-known complication of breast implants.
–2~5.3 ruptures/100 implants x years
–Rupture-free survival
• 98% at 5years,
83-85% at 10years
1.
Types of breat implant
* Advantage
–Natural weight and feel,
easy molded & shaped.
–Lower rate of rupture/malpositon/asymmetry
–Recent 4th generation cohesive gel : Resistant to rupture
* Disadvantage
–Cannot be adjusted in size during intraOp.
–More common contracture at over 5years.
* Advantage
–Natural–Flexibility in adjusting content amount
–Smaller incisions
* Disadvantage
- If overfilled: firm ball, scalloping look
- If underfilled: palpable/visible shell wrinkling
–Heavier : tissue thinning with inferior displacement–Firmer,
less natural feel
Under to pectoralis muscle fascia
* Advantage
–More natural breast contour
–Less capsular contracture rate
–Nipple sensation protected
-More acurate MMG
* Disadvantage
–Longer postOp recovery
–Difficult reoperation
–Lift the parenchyma with some ptosis
Superficial to pectoralis muscle fascia
* Advantage
–More easy to control shape
–Short recovery time
* Disadvantage
–Less natural breast contour
–Common capsular contracture rate
–Nipple sensation loss–Interfered MMMG
2.
Causes of Implant Rupture
• Deterioration/degeneration with time
• Trauma
• Effect of closed compression fibrous capsulotomy
• Compression during MMG
• Unknown or Not defined clearly : Most Common
–Asymptomatic at onset time
–Almost cases occurred without definite trauma
3. Classification of implant rupture
Classified according to integrity of fibrous capsule normally formed around to implant
–More frequent(77–89%)
–Polymer implant capsule tear.
–Silicone remaining within fibrous capsule
–Silicone leaks outside from fibrous capsule
–Damage to surrounding normal tissues
: granuloma formation,
fibrosis,
distant migration
4.Review of Multimodality imaging findings and advantages of each imaging technique
1) Mammography (Fig.1~5)
–Periprosthetic hyperdensity
- “Gel streaming” phenomenon : conic image projecting from edge lesion
–Diffuse,
ill defined
–Lobular,
spherical
–Silicone lymphadenopathy
–Difficult to detect
* Less value in implant evaluation.
- Interrupted full view of the breast parenchyma
- Lesion should be confined to imaging range
- Pain makes compression impossible
- Intracapsular rupture cannot be identified
* To overcome these limitations,
Eklund technique is recommended
: Eklund technique (Fig.6)
- For examinate breast with implants
- Posterosuperior displacement of the implants by pushing towards to chest wall
- Anterior traction of the breast
- Improves image quality and amount of breast tissue imaged
2) Ultrasound
- Intracapsular rupture (Fig.8~10)
–“Stepladder” sign
Polymer shell floating within the implant
This manifests as echogenic lines
–“Serpentine”,
“ball” sign
Hyperechoic linear elements floating within the silicone gel
- Extracapsular rupture (Fig.11~15)
–“Echogenic noise” “Acoustic shadowing”
Hyper/hypoechoic leakage(formed to siliconoma,
granuloma)
–“Snow storm” sign
Microscopic accumulation of silicone.
–Axillar silicone nodules.
–Discontinuity of breast implant capsule
* Cheaper than MRI
* Valuable when MRI is contraindicated.
* Readily availabe and accessible
* Easy to correlation with physical examination.
* Targeted investigation in interesting site.
* Limitation
High operator dependent.
Low sensitivity : High false-negative rate
3) CT,
MRI (Fig.16~24)
- Early intracapsular rupture
–“Tear drop”,
“key-hole”,
“noose” sign
Invagination of silicone membrane with a droplet of silicone
–“Subcapsular line” sign
Line running parallel,
just beneath to fibrous capsule,
both end fused to surface of the implant
–“C-shape” sign
Patch of silicone between polymer & fibrous capsule
Forms ‘c’ on the back of the capsule collapse occurs
–“Linguine” sign
The most reliable clue for intracapsular rupture
Low SI multiple curvilinear lines within the high SI silicone gel
–“Train rail” sign
Rupture of double lumen implant
2 hypodense parallel lines forming double-contoured subcapsular line
–Bulging contour
Probability of rupture
Mimic herniation
–“Rat-tail" sign
Medial linear extension of silicone along the chest wall
–“Salad oil”,
“Droplet” sign
Water/serum split into silicone gel
Multiple high SI foci on water suppresion T2WI or hypoSI foci on FS T1WI within implant lumen : implant rupture reliable signs
–Free silicone leakage
Formed to Siliconoma,
granuloma
May enhance similar to breast carcinomas
Distant migrated nodule
Discrete foci(High SI in water suppresion T2,
Low SI in FST1)
* Generally regarded as the gold standard
High sensitivity(89%)
High specificity(97%)
* Higher cost
* Contraindicated patients
5.
Review of diagnostic pitfall and recommendation
- False positive finding with (Fig.
25)
–Gel bleed
Silicone passes through an intact semiporous capsule
–Only Key-hole/noose/droplet sign
Misrecognized radial folds.
–Periprosthetic fluid.
–Double lumen implant.
Easily misinterpreted as the stepladder sign/ post-rupture collection.
–Bulging contour result from herniation.
–In symptomatic patient
Non-contrast MRI
–In asymptomatic patient/for investigating of focal area
→ US for screening
→ Positive
→ Surgical decision can be made without MRI.
→ Negative
→ Recommend MRI when there is doubt for intracapsular rupture/clinically.
–Patients with oncoplastic surgery
→ Dynamic contrast MRI
Evaluate the breast gland parenchyma
MMMG & sono considered for findings not visible by MRI (microcalcifications..)