Augmentation Mammoplasty: Normal and Abnormal Findings with Mammography and US1 Marie

A. Ganott,

Zahra

MD

#{149} Kathleen

S. Ilkhanipour,

A retrospective tion

MD

review

mammoplasty

of (n

133

and silicone injections (n mal appearance of various normal variations (wrinkles, true implant complications of silicone

gel,

mities).

The

malities

in

and

capsular

for

(US)

or

implant special

are

Both

should

be

poses

paque sion

displacing

Index 00. 1298

The

breast the

terms: #{149} Breast

RadioGraplilcs I From burgh

a special

Breast,

of the

implant

tissue

00.30

panenchyma

interferes

pattern. #{149} Breast

tends

to cause

In addition,

00.458

breast

Breast.

#{149}

radiography,

prostheses.

in

or rec-

obtained

technique be

adequate

and

of the are

Breast,

#{149}

special abnor-

interpretation, by

the

mammographic

prostheses

the

or reconstructive presence of an

obscured

compaction

00.454

with

or other of palpable

augmentation evaluation. The can

with

views

Coned-down opacities views are

compresbreast

subject

surgery,

radio-

00.46

tissue

by

to compli-

#{149} Breast,

US.

00.11

12:281-295

the Section of Breast Imaging, SchoolofMedicine. Bellefield

scientific assembly. Receivedjune her 16. Address reprint requests RSNA.

mammographic

and

anteriorly.

parenchymal

for breast

also

parenchyma

neoplasms.

1992;

who have undergone for mammographic

problem

proportion

implant. of the

of women being seen

defor-

difficult,

mammographic

implant displacement technique. Tangential combined with US are best for the evaluation malities and suspected silicone implant rupture.

a large

nor-

abnor-

more

examination are required. are suggested for asymmetric masses, and magnification

Ekiund

since

10),

=

and

parenchymal

views

implant

(n

the

calcification,

of breast

microcalcifications:

U INTRODUCTION Increasing numbers mammoplasty are

augmenta-

to establish

capsular

evaluation

ultrasound

ommended

undergone

mammoplasty

undertaken

of a radiopaque

with physical spot views mammographic

had

MD

types of implants, to establish a range of valves, minor bulges), and to recognize (collapse of a saline prosthesis, leakage

and

presence

frequently

conjunction compression ill-defined

who

reconstructive 1) was

=

MD

A. Costa-Greco,

patients

contracture,

detection the

#{149} Maria

122),

=

M. Harris,

Magee-Womens Towers, Suite 28, 1991; to M.A.G.

revision

300,

Hospital Breast Care and Diagnostic 100 N Belleheld Ave. Pittsburgh,

requested

October

1 and

received

Center. PA 15213. l)ecembcr

University From the

of Pitts1989 RSNA

13; accepted

Decem-

1992

281

Figure

1. Saline-filled implant. A 45#{176} mediolatenal oblique view a saline-filled implant. The radiopaque silicone envelope is (short straight arrow) and envelops the more radiolucent Note the valves used to fill the implant (solid curved arrows)

shows wrinkled

saline. and ring (open

curved

ous

the

wine

marks

cations ical

that

arrow)

surgical

may

mimic

examination.

used scar

breast

These

to position

(long

the implant.

straight

disease

at phys-

problems,

which

make detection and evaluation of breast renchymal abnormalities more challenging, can be diminished with special mammographic techniques and ultrasound (US). Since

the

development

of the

implantable prosthesis types of implants have variety of sizes, shapes, in different

first

pa-

silicone

in 1963, numerous been designed with a and surfaces, resulting

radiographic

appearances.

The

shell of the implant is composed of a silicone elastomer, the surface ofwhich may be smooth, rough, or coated with polyurethane. Some implants have a single lumen containing silicone gel or saline, whereas others have two on more compartments. This

ance

article

describes

of various

also

tion.

collapse

and

Concomitant

with

mammography,

and

tehniques used and characterization

It

to the or

leakage,

capsular

breast

detected

in the

positions.

related

as implant

contracture,

malities

appear-

placed

subpectonal

complications

such

capsular

normal

of implants

and

describes

implant

the

types

retroglandular

A cutane-

arrow).

calcifica-

parenchymal

physical US are

in their are

abnon-

examination, reviewed,

optimal discussed.

and

the

visualization

Twenty-six around

bilaterally

tients plants

in

this

series.

(41%),

pointing

US was

performed

1986

in selected

screen-

through

1989.

patients

(total,

included

metiy

in

masses patient,

into

Ofthe

total,

122

augmentation postmastectomy had undergone the

breast

patients

had

un-

mammoplasty, 10 had reconstruction, direct silicone injec-

parenchyma.

implant

collapse

in eight,

ing

in 22

U

were

in

of these breast identified

breast

parenchymal cysts

NORMAL

RadioGrapbics

patients implants.

had

‘

‘

1 i patients. single-lumen-

Five and

tion

lope. silicone

U

Ganott

Ct al

and

exhibited

calcifications

benign in one

APPEARANCE

OF

IMPLANTS

Silicone

implants,

‘mixed’

asym-

in six

at surgery.

three type

dou-

defor-

superior

patients, in three patients, carcinoma and senoma in one patient.

patients,

to fill the

double-lumen

in

deformities. parenchymal abnorin 33 patients, includ-

used

had

saline,

implants

saline

patients

seen

in nine,

Some

glandularly,

in

paimin

Six

Other

10,

undulations

in one.

benign

with

in 33 patients,

bulges indentations

. Saline Implants Saline on inflatable implants an outer silicone envelope

present

12.

was

implants.

implants were placed in 1 13 patients; 77% were placed retroglandularly (anterior to the pectoral muscle), and 23% were placed subpectorally. Saline implants, all placed netrowere

caloccurred

in

all patients

more than one Concomitant

44

years).

10,

herniation

malities

tions

U

reconstructive

underwent

unilaterally

and mixed

mities

39) with a Toshiba 900 unit (Tokyo) with a 7.5 MHz linear-array transducer. The patients were aged 30-70 years (mean, dergone undergone and one

282

or

which

leaks; all of the leaking retroglandular position

Saline

including

underwent

All patients from

14 and

capsular

implant,

four patients. Six patients exhibited radiographic evidence of capsular contractune, five cases ofwhich occurred in retroglandular silicone implants and one in a subpectonal silicone implant. Predominantly minor implant deformities were seen in 76 patients (57%). Wrinkles were the most common deformity observed and were visible in 54 patients

ble-lumen,

augmentation

exhibited

the

had silicone were in the

U CLINICAL POPULATION The material presented in this article is based on a retrospective review of 133 patients who mammoplasty. film mammography

patients

cification

the

Often

ones,

visible

implant,

implant,

Saline

and

implants allowing

(Fig 1) consist of filled with normal

“rings” wrinkles

are

less partial

Volume

are

the

used

valves

to posi-

in the

enve-

radiopaque visibility

12

than of tis-

Number

2

.

..

:

2, 3-

Figures

(2)

Retroglandular

silicone

implant.

The

outer

silicone

envelope

..t_

be visibly

cannot

‘‘

5,.,..

.

.

‘

.-

.-

distin-

guished from the silicone gel filler, as both are equally radiopaque. Portions of the surrounding breast tissue are obscured by the radiopaque silicone. An opaque benign calcification (arrow) easily seen on the craniocaudal view (a) is completely obscured by the opaque silicone on the 45#{176} mediolateral view (b). (c) US image of a silicone implant shows an echogenic envelope anteriorly and posteriorly (curved arrows) surrounding the anechoic gel filling. Reverberation echoes are frequently seen (open arrows) just deep to the anterior wail. An anechoic Kitecko standoff gel pad (3M, St Paul) was used between the transducer and the skin (straight solid arrows). (3a) Superior pointing or wrinkling of the superior aspect of the implant (arrow) can

be seen

on the mediolateral

projection

of retroglandular

palpable because of their proximity to the skin and thesis shows it to be pliable and subject to wrinkling.

sue detail penetrated

through imaging

the implant technique

when an ovenis used.

silicone can

simulate

smooth so

implants. a mass.

that

contour. wrinkles

visualized ever, superior superior aspect the mediolateral monly

.

Silicone

Silicone

envelope 2).

They

March

Implants implants

filled are

1992

consist

with

usually

of an

a viscous oval

outer

silicone

silicone

in shape,

with

gel a

(Fig

thus

mimicking

These (3b)

wrinkles

Photograph

Silicone in the

than pointing, of the view a breast

Ganott

may at times of a silicone

is very

be pros-

radiopaque,

envelope

are

less

com-

Howor wrinkling of the implant may be seen on and may be palpable, in

saline

mass

et

implants.

(Fig

al

3) (1).

U

RadioGraphics

U

283

a.

b

c

4. Subpectoral silicone implant. The pectoral muscle ovenlies the implant in the craniocaudal (a) and 45#{176} mediolateral oblique (b) views. In this case, the pectoral muscle (arrows) completely overlies the implant. In some patients, the inferior aspect of the implant may not be covered by muscle. (c) US image shows the pectoral muscle (large arrows) overlying the implant. Ribs are visible deep to the implant (small Figure

arrows).

Figure

torally noma

5. Bilateral silicone implants were after a left modified radical mastectomy and a right subcutaneous mastectomy.

(curved arrow) and pectoral the implant on these opposed views

of the

right

Silicone

and

implants

placed subpecfor carciThe skin

muscle (straight 45#{176} mediolateral

arrows) overlie oblique

left breasts.

may

be

placed

retroglan-

dulanly (most common in our series) or beneath the pectoral muscle (subpectonal) (Fig 4). In patients with little or no breast tissue, the implant contour may be visible and the

edge

palpable

if placed

retroglandularly.

Therefore, subpectonal implants have been advocated for small-breasted women and for postmastectomy reconstruction to achieve cosmetic

improvement

subpectoral avoid

masking

mastectomy that with

284

U

RadioGraphics

placement

(Fig

5)

has

been

recurrent

patients. augmentation

U

Ganott

carcinoma

(2,3).

Also,

advocated

to

in post-

It has been reported mammoplasty, there

et

al

Volume

12

Number

2

Figures implant. shows (white

6, 7. (6) Double-lumen A 45#{176} mediolateral view a saline-filled outer bag arrow) surrounding an in-

ner silicone prosthesis (curved anrow). Wrinkles are visible in both the saline (long arrows) and silicone (short arrow) compartments. (7) Mixed implant. A 45#{176} mediolatera! oblique view shows a singlelumen

implant

cone

that

injected

to adjust

plant

at surgery.

more

radiolucent

plant.

Saline

only because gravity.

is better

preservation

subpectoral

of nipple placement

(4)

sensation than

with

retro-

glandular implant placement. During pectoral muscle contraction, subpectoral implants may be distorted (5) and are not recommended for weight lifters. . Other Types of Implants Various other types of implants have been manufactured, including double lumen, reverse double lumen (Fig 6), and mixed silicone and saline in a single lumen (Fig 7). Of these, the type we encountered most often was the double-lumen implant, which consists of a saline-filled outer bag surrounding an inner silicone prosthesis. This arrangement allows size adjustment for asymmetry at implantation and combines some of the advantages of silicone and saline implants. If the saline

compartment

collapses,

a sizable

im-

plant remains. The possibility of silicone caping into the surrounding tissue is decreased when a double-lumen implant is (6), since the outer envelope can act as a rier if silicone gel escapes from the inner

es-

.

Normal

Silicone appearance with

US and

sili-

saline

had been

the

size

Note

of the

of

(arrows)

portion

in

of the im-

is usually

seen

of its greater

Appearance

im-

the area

saline

the dependent

with

contains

gel into which

of

infeni-

specific

Implants

saline implants have a similar consisting of an anechoic bag

a reflective

anterior

interface

US

between

the implant roglandular plant and

and the breast parenchyma in retimplants and between the imthe pectoral muscle in subpectonal

implants.

The

posterior

ficult to visualize nal reverberation (Figs

2c,

4).

nat valves

can

interface

because echoes

Occasionally,

may

be

of its depth. are frequently wrinkles

be observed

(see

dif-

Interseen and

inter-

Fig 23b).

Free Silicone Injection Before the widespread use of implantable prostheses, free silicone was injected directly

I

into

the

breasts

for

augmentation.

This

proce-

dune was commonly performed in the i960s but is now prohibited in the United States. Liquid silicone coalesces into droplets that may

bolize

migrate

more

to regional

distally.

lymph

No causal

nodes

relation

or

em-

be-

used bar-

com-

partment.

March

1992

Ganott

et al

U

RadioGraphics

U

285

Figures 8, 9. (8) Direct silicone injection. A 45#{176} mediolateral oblique view of a patient injected 20 years before with free silicone shows multiple opaque globules with calcified rims (arrow). A true neoplasm could be easily obscured by the numerous silicone globules. (9) A craniocaudal projection obtamed with an overpenetrated technique shows breast tissue detail

through

the saline

implant.

capsular calcifications easily seen through

Benign

(arrows) the implant.

are

tween silicone and human breast carcinoma has yet been established (7). Local complica-

implant

tions

have

with

pain,

lymphadenopathy,

been

reported,

including

with

the

mediolateral

infection,

use

and

of orthogonal

45#{176} mediolateral

and.

craniocaudal

of hard granulomatous masses. The subsequent nodularity of silicone mastopathy may

be impossible

ing

to distinguish

the

development

from carcinoma

at physical examination (8). Mammographically, multiple radiopaque silicone globules, some with rim calcifications, are seen. These globules are most often 2 cm or less in diameten and can obscure the adjacent breast parenchyma (Fig 8). U TECHNICAL It has been shown can totally obscure soft-tissue sis

(9).

CONSIDERATIONS that a radiopaque microcalcifications

masses The

hidden

lower

behind

radiopacity

plant allows visualization renchymal lesions through when an overpenetrated (Fig

9).

83%

of the

by an

According implant

on

crandiocaudal that less breast

the

prosthe-

routine

et a! (10), may

be

im-

22%obscured

mediolatenal

These authors stated was hidden behind

obscuring

displacing

pressing breast

more vigorously tissue, resulting In our

the tisdun-

subtle

compression

posteriorly

10).

views.

compresses so that the spread out

ab-

over

the

because of the risk these problems, Ekthe technique of the

implant

and

com-

directly in better

over tissue

the detail

experience,

this

is more

easily

performed in patients with subpectoral implants and in those with a larger amount of breast tissue relative to the implant size. The posterior displacement views obtained

of some breast pathe prosthesis technique is used

tissue

views. tissue

the

thus Vigorous

implant is contraindicated of rupture. To overcome lund et al (1 1) described

(Fig

implant and

of a saline

to Hayes

glandular

mammography,

normalities.

(90#{176}

as compared

The presence of an implant surrounding glandular tissue sue is compacted rather than

and

views

craniocaudal)

and

the

in both

the

oblique

projections

craniocaudal

and were

mediolatenal

introduced

by

Ek-

lund et a! (1 1) to supplement the standard craniocaudal and mediolatenal views and should not replace them. When Eklund views are obtained, the most posterior portion of the breast is not imaged. To visualize the posterior portion of the breast tissue and to adequately visualize the implant, standard views should be obtained in all patients. Thus, obtaming

four

views

of each

breast

has

been

ad-

vocated.

286

U

RadioGrapbics

U

Ganott

et al

Volume

12

Number

2

1..

Figures 10, il ofmicrocalcifications nique of posteriorly

(10)

Microcalcifications. (a) Standard (arrow). (b) Magnified compression displacing the subpectoral implant

row). Note the pectoral the envelope of a saline lapsed

silicone

Factors

muscle implant

envelope

that

(curved arrow) overlying is damaged or punctured,

(arrow)

affect

the

is markedly

ability

of the

implant,

and

the

wrinkled

to evaluate

breast parenchyma mammographically dude the size of the implant relative amount of surrounding breast tissue, tion

45#{176} mediolateral view obtained better demonstrates

shape

the

into the the posiof the

im-

the silicone the prosthesis and

folded

breast,

itself.

the

presence

requires graphic

or

sonographic

ization

abnormality

of an

in characterizing

implant. In patients tune, the rounded, plant makes external breast and posterior plant more difficult cially

if the

by

the

with capsular contracfirm, noncompliant imcompression of the displacement of the imfor the technologist, espe-

implant

is in the

retnoglandular

tissue reliable

the

screening

demonstrate

a mammoThe

aids

in the

suspected prosthesis,

at physibut

since

breast

implant,

especially or

from

if the

performed

palpable

of only

a

it cannot and

distin-

portions

when

because

presence

of all it is not

US is useful lesions the

Eklund

use

visual-

visualization

microcalcifications. them

dense

US

method,

guishing

the

and

col-

abnormality

for

US allows

overlying

The

abnormality.

views

paction

parenchyma

search

of tangential examination.

deflate.

of a palpable

a meticulous

cal

adjacent

may completely

on

plant. Breast tissue detail is probably better seen in patients with small implants relative to the size of the breasts and with implants placed subpectorally as a result of less comof the

oblique view poorly shows a cluster by using the special Eklund techthe calcifications (straight animplant. (11) Implant collapse. When

breast

technique

cannot

of capsular a small

of the tissue

is be

contracture amount

or

of breast

tissue.

position.

Manual settings of kilovoltage and milliampere seconds are often required to optimally visualize the breast parenchyma, since placing the phototimer under an implant may produce overexposure of the surrounding breast tissue.

Because of the possibility chymal lesions being obscured

of breast

mammographic

augmented

March

1992

views

of the

on

paren-

U

COMPLICATIONS

.

Implant

IMPLANTS

Failure

A radiographically tion

is collapse

The

silicone

partially

OF

dramatic of a saline

envelope

collapsed.

may

implant

complica-

prosthesis

(Fig

be completely

Clinically,

deflation

1 1).

or of the

routine

Ganott

Ct

al

U

RadioGrapbics

U

287

Figures

12-14.

(12)

Silicone

leak.

A patient

presented

with

induration

and

skin

puckering

at the

site

of a

biopsy that had been performed 3 months earlier. A 45#{176} mediolatenal oblique view shows deformity of the implant (black arrow) at the biopsy site and silicone extruded into the breast tissue (white arrow). Presumably, the leak occurred during the original biopsy. Subsequent surgery revealed fibrosis, foreign material (silicone), and foreign body giant cell reaction. (13) Silicone leak. A 45#{176} mediolatera! oblique view shows a large collection of free silicone (arrows) extending superiorly along the pectoral muscle. This was not present on the mammogram obtained 7 years earlier. Silicone leaks can remain confined to the vicinity of the implant, as in this case, or migrate in the form ofglobules. (14) Silicone leak. A patient who experienced severe pain on vigorous compression at mammography 1 year earlier presented with a mass in the left upper breast. (a) A 45#{176} mediolateral view of the left breast demonstrates a silicone leak with multiple silicone globules (straight arrows) migrating along the planes of the pectoral muscle. The palpable mass (curved arrow) comesponded to extruded silicone and associated fibrosis. (b) US image demonstrates free silicone globules (ar-

rows)

within

hyperechoic

fibrous

tissue.

12.

13#{149}

14a#{149}

saline-filled Leaks are

implant occurs over 1-2 days (5). most likely to occur in weakened areas of the silicone envelope such as seams, valves, or wrinkles (especially in undenfilled implants). Continued abrasion of wrinkled surfaces

may

result

in fatigue

fractures.

The

prevalence of collapse is decreased when thicker silicone envelope is used (5,6). Leakage of silicone gel may occur after etrating

omy,

288

U

RadioGraphics

or

blunt

or secondary

U

trauma,

after

to decomposition

Ganott

Ct

al

closed

a pen-

capsulot-

of the

Volume

12

Number

2

15. Capsular tient presented with breast. (a) Opposing

contracture. Three years after retnoglandular placement of silicone clinical symptoms of capsular contracture consisting of a firm, tender, 45#{176} mediolateral oblique views show that the right implant is spherical

Figure

implants, the paprotuberant night compared with

on the right is visibly thickened (opposing curved arrows) compared capsule on the left (opposing straight arrows). (b) Close-up views left implants enable better visualization of thecapsules (annows).k$

the left implant. The capsule almost imperceptible normal non aspects of the night and

I

:

with the of the infe-

s4’

-

b.

silicone

envelope

tient

may

site

of the

in older

present

with

silicone

implants.

The

a palpable

leak.

14).

The

free

silicone

incision

site,

(6,7).

The

nation

through

graphically, Most

along

the

nipple

any

not when

distorted

sili-

microscopic

droplets

envelope.

of silicone

implants

modified

.

have

shell

Capsular

Normally,

been

designed

to reduce

gel

body

forms

a thin

or “fibrous capsule,” in an attempt to wall

ject.

With

tissue capsules

a

careful

in many surrounding wider

1.5

lack

implant. mm

In our were

postoper-

consequently

be-

(5) and firm to palpabecome painful or visibly appears

inflamed.

of compressibility

(Fig

is usually

of the

adjacent

breast

of the

surround-

thickening 15).

but

Histologically,

not

is on

which are not rounding of the

of the

and

capsule

always

the thickened

cap(6).

Capsular contracture is the most common source of patient dissatisfaction and has been reported in up to 70% of patients, most com-

imob-

ported

can

tecting

1-mm-band

implant

compression

in 23%-60%

implants

of colla-

every foreign

a capsule

as a thin

the than

layer

around off the

observation,

cases

ing sule

monly

(12).

Contracture the

and

implant,

with

occurs

few

Radiographic findings, in every case, include

tune develops double-lumen

gen, plant

be seen

bleed

first

occasionally

parenchyma,

accumu-

late around the prosthesis and may contribute to capsular thickening, but some may migrate through the reticuloendothelial system to regional lymph nodes or more distally (5). Newer

The

and

breast. present

molecules

silicone

the

con-

that

The diagnosis of capsular contnacture made with physical examination, based

mammo-

silicone

an unbroken

within

area.

firmness

visible

abnormal

capsule

comes more spherical tion. The breast may

dissemi-

before

is an

fibrous

frequently

surface

to to the

to the

of the

ative months but can occur any time after sungery (6). The capsule contracts and encases the implant more tightly, thus reducing its

is implanted.

“bleed,”

occurs

penetrate

ducts

be considered

gel

in the collec(Fig

reported rarely

contracture

stniction most

ofsilicone

gel prosthesis

Silicone

migrate

consequences

should

cone

may

and has been lymph nodes,

or

at the

Mammographically,

free silicone in the breast can appear form ofglobules (Fig 12), a confluent tion (Fig 13), or a combination ofboth pectoral muscle travel to regional

Capsular

pa-

mass

could

(6,12).

with be

due

(6,12).

Capsular

less frequently implants than It is also

subpectoral partly

contracture

with with

less

contrac-

saline silicone

commonly

implants, to greater

but difficulty

through

and gel re-

this in de-

the

greater

bulk

al

U

RadioGraphics

of series,

considered

to be thickened.

March

1992

Ganott

Ct

U

289

Figures 16-18. (16) Capsular calcifications. (arrows) on the surface ofa 14-year-old saline eral oblique view of the implant surface shows

A craniocaudal projection shows implant. (17) Capsular calcifications. jagged projections of calcifications

diffuse capsular calcifications A close-up 45#{176} mediolat(black arrows) adherent

to

the surface of the silicone envelope projecting as spikes within the thickened capsule (white arrow). An overpenetrated technique allows optimal visualization ofcapsular calcifications, which can be difficult to appreciate, adjacent to the radiopaque silicone implant. Breast tissue is poorly visualized because of the ovenpenetrated technique. (18) Bulge. A 45#{176} mediolateral oblique view shows a large bulge (arrows) in the superior aspect of the silicone implant.

of overlying tissue urethane-coated, are being evaluated

(13). Rough-surfaced, and low gel bleed for their efficacy

ing

of capsular

the

incidence

contractune

(12). The polyurethane-coated recently been taken off the Food and Drug Administration possibility

of breakdown

a carcinogenic

The

reaction contracture antibiotic

into

substance.

cause

of capsular

contracture

silicone

gel

contributing at surgery,

bleed,

(6,13). Strategies have included treatment,

massage. Steroids surgically created plant or into the plant.

and

and

is contro-

factors micro-

foreign

to deter steroid

are

body

capsular injections,

postoperative

can be injected into pocket surrounding lumen of an inflatable

Treatment of capsular contnacture consists of closed or open capsulotomy or capsulectomy. During closed capsulotomy, the breast is squeezed

implants have market by the because of the

of polyurethane

versial, but suggested hematoma or infection scopic

polyimplants in reduc-

causing rounding with

strenuously

between

rupture of the the implant.

this

procedure

include

hematoma,

formed,

The

the

new

a new

existing

implant

position

implant

may

can

or may

RadioGraphics

U

Ganott

et al

ec-

be

not

causing rupture of free If an per-

replaced.

be placed

in

(12).

breast

the the imim-

I

Other

Complications

Capsular calcification, questionable clinical approximately 20% or saline

an incidental finding significance, was seen of patients with either

implants

and

more frequently when implants present for many years. In this never detected in the capsules

U

hands,

centric rupture of the fibrous capsule implant asymmetry or henniation, and of the silicone envelope with extrusion silicone into the surrounding tissues. open capsulotomy or capsulectomy is

silicone

290

two

fibrous capsule sunThe risks associated

Volume

was

of in

observed

had been series, it was of subpectoral

12

Number

2

Figure 19. Asymmetric position of implants. Infections necessitated several surgical revisions of the left implant. Extensive scarring infenionly resulted in displacement of the

left implant superiorly in companiwith the right breast implant, as seen on these opposed 45#{176} mediolateral oblique views. This asymmeson

try was physical

implants.

The

calcifications

may

be

focal

(Fig

9) or diffuse (Figs 16, 17) and may be difficult to visualize at the margin of radiopaque silicone implants because of similar radiopacity. The cause of calcium deposition within the fibrous capsule is unknown. A chronic inflammatory response has been suggested (14). Minor deformities, bulges (Fig 18), and undulations (nipples) of the implant are common and are sometimes palpable during physical

examination.

common percentage Wrinkling inflatable silicone

Wrinkles

are

deformity and were (41%) ofpatients is most prominent saline implants but implants,

penetrated

especially

mammographic

Asymmetry

of shape

1992

pocket, marked or asymmetric

(Fig

19).

. Concomitant Abnormalities We observed ties

in 33

tion)

on

Benign

most

patients.

seen in a large in our study. in undenfilled, can be seen in

patients),

when

technique or positioning

the right and left implant can capsular contractune, unilateral lapse, migration of an implant

March

the

gical plant,

an

over-

is used.

also quite apparent examination.

deformity placement

Breast breast

patients

Parenchymal

were

commonly

masses

study

US images,

calcifications

Less

abnormali-

ofour

mammograms,

breast

of one imat surgery

panenchymal (25%

noted

(four

(ie

, magnification, spot,

populaor

were

patients),

in 22 cysts

and

(six

seroma

and

tangential,

coned-down-

or

technique

Eklund

both.

seen

(one patient). Accurate localization mal visualization of these abnormalities quently required extra mammographic compression

during

optifreviews

between

be secondary to saline colwithin the sun-

Ganott

et al

U

RadioGraphics

U

291

Figures 20, 21. not be visualized

double-lumen prosthesis

(20) Palpable mammographically

implant (black

arrow).

breast

consisting (b)

abnormalities. within the dense

of a saline-filled

US image

The patient presented with tissue. (a) A 45#{176} mediolateral

outer

demonstrates

bag (white

a cyst

arrow)

surrounding

mass view

an inner

that could shows a

silicone

which corresponds to the palpable mass. The cyst causes a slight bulge of the overlying skin (open arrow) . (2 la) Craniocaudal view questionably demonstrates a mass (arrows) that was palpable in a 46-year-old woman. Coned-down posterior displacement view did not successfully depict the mass because of its proximity to the silicone implant. (2 ib) US image clearly demonstrates the 1 .4 x 0.9-cm solid mass (solid arrow), adjacent to the echogenic enveofthe implant (open arrows). Cytologic I ‘-s from subsecuent US-ruided fine-needle aspiration ----

292

U

RadioGraphics

U

Ganott

Ct

al

(solid

a palpable oblique

arrows),

----..-S

Volume

12

Number

2

Figures 22, 23. (22) Palpable small lump in the left breast. A small bulge near the inferior aspect of the retroglandular silicone implant was best appreciated on the US image (large arrow) . There was no underlying breast abnormality. US enabled identification of the bulge as the source of the palpable abnormality. The inferior edge of the implant was also palpable as a ridge (small arrow). Palpation of the implant was facilitated by its proximity to the skin. (23) Palpable abnormality was present in the lower outer quadrant in a patient with a retroglandular saline implant. (a) Craniocaudal view shows the valve (short arrows) used to fill the implant. A wire (thin arrow) marks the external cutaneous scar. (b) US image demonstrates that the palpable abnormality represented a valve (solid arrows), which could be readily detected during physical examination. Note the wrinkled anterior surface (open arrow) of the implant. There were no underlying

t.---..,#{149} .-

.-----..

.

5,.

ble

Among mass

sion

(cyst,

implant 3 1%,

26 patients (Figs 20-25), solid

presenting with a palpaUS revealed a true le-

mass,

or

abnormality and

no

seroma)

(bulge,

abnormality

malignancy

was

79% ofour

patients

observed

(Fig

with

to

ation or

US

(Figs

10,

20,

21).

US was

used

evaluate masses seen on mammograms and palpable abnormalities. When an implant is present, an asymmetric opacity seen on only one view is more problematic. A mass could be hidden by the implant on obscured within compressed glandular tissue on one or both

to

of asymmetric

pression displacement

25).

in

one

However,

were

and 36% were As the patient one can expect among these

poppa-

increase.

mammographic views)

Only

implants

We suggest the following workup of the problematic

23b.

an

or leak)

in 38%.

younger than age 50 years, younger than age 40 years. ulation with implants ages, the prevalence of carcinoma tients

in 3 1%,

valve,

spot

guidelines patient.

opacities

masses, views

ill-defined

coned-down

obtained

technique

or

for the evalu-

For

com-

with described

the

implant

by

Eklund

views.

March

1992

Ganott

et al

U

RadioGraphics

U

293

Figures 24, 25. (24) A patient with silicone implants for 16 years presented with a mass in the upper outer quadrant of the breast. A 45#{176} mediolatenal view demonstrates a silicone leak (straight arrow) that comesponds to the palpable mass, which was identified with a metal marker placed on the patient’s skin (curved arrow). A faint line ofdemancation can be appreciated between the implant and the extraluminal collection of free silicone. This demarcation may be difficult to detect because of the similar radiopacity of the silicone inside and outside the silicone envelope. (25a) A clinically evident carcinoma (arrows), manifested by an area of thickening and skin dimpling, is almost completely obscured by the nadiopaque saline implant on this craniocaudal view and was completely obscured on the mediolatenal view (not shown). (25b) US image reveals an irregularly manginated mass (solid arrows) adjacent to the implant. The anterior margin of the implant (open arrows) is obliterated in the region of the mass, which could be due to acoustic attenuation. At surgery, ‘ ‘invaded’

an infiltrating ‘ the silicone

et at (1 1) are alization

ductal carcinoma envelope.

recommended.

For

of microcalcifications,

views

obtained

using

better

fications,

with

present

the

or silicone

optimal

Eklund

tightly

When

the

rupture

Clinically

is

implants.

Minor

common. tune. breast US,

deformities

Clinically

include

silicone

in the

is sus-

appearance

and

important leakage

wrinkles

of

capsular

breast

tailored

mammographic

U

RadioGrapbics

U

Ganott

Ct

appearance

and

of the

true

complications.

are

frequently

in the silicone.

in distinguishing

a

various

and

special

Knowledge of the

types normal

of the augmented

of implants variants

from

REFERENCES 1.

Grant

EG, Ciglay OS, Mascatello VJ. Imreguof silastic breast implants mimicking a soft tissue mass. AJR 1978; 130:461-462. McDonald HD. Reconstruction of the breast. In: Lippman ME, Lichter AS, Danforth DN, eds. Diagnosis and management of breast cancer. Philadelphia: Saunders, 1988; lanity

2.

views.

al

to have

or wrinkles by leaking

is critical

required.

in differentiating

468-485.

3.

294

often

aids

Detection ofdisease in the augmented is enhanced by physical examination, and

helpful

technique are

radiographic

are contrac-

appeared

masses

by bulges, valves, and occasionally

mographic views

complications

and

palpable

and

true breast lesion from palpable portions of the implant. Because of the technical problems in imaging the augmented breast, mam-

U variation

implant

US is particularly

mass

pected, tangential or other special views, as well as US, are recommended. In patients in whom posterior displacement of the implant cannot be achieved (usually due to capsular contracture or scant breast tissue overlying a retroglandular implant), US is especially valuable in characterizing a palpable abnormality. U SUMMARY There is a wide

to the

caused implant

microcalci-

a palpable

implant

adherent

visu-

technique,

over

helpful.

found

magnification

compression are

was

Chang WHJ, mammoplasty.

PetryJJ, eds. Augmentation In: The breast: an atlas

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12

of re-

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2

construction. 1984; 29-56. 4

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implantation.

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6.

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Guthnie R, Schwartz G. Reconstructive and aesthetic mammoplasty. Philadelphia: Saundens, 1989; 97-2 13. Burkhardt B. Breast implants: a brief history of their development, characteristics, and problems. In: Gant TD, Vasconez LO, eds. Postmastectomy reconstruction. 2nd ed. Ba!timore: Williams & Wilkins, 1988; 68-83. Morgenstemn L, Gleischman SH, Michel SL, RosenbergJE, Knight I, Goodman D. Relation offnee silicone to human breast carcinoma. Arch Sung 1985; 120:573-577. Cruz G, GillooleyJF, Waxman M. Silicone granulomas of the breast. N Y State J Med 1985; 85:599-601. Gumucio CA, Pin P, Young VL, Destouet J, Monsees B, EichlingJ. The effect of breast implants on the radiographic detection of

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microcalcification and soft-tissue masses. Plast Reconstr Sung 1989; 84:772-778. Hayes HJr, Vandengrift MS, DinenWC. Mammography and breast implants. Plast ReconstrSung 1988; 82:1-6. Eklund GW, Busby RC, Miller SH, Job TS. Improved imaging of the augmented breast. AiR 1988; 151:469-473. BostwickJ III. Plastic and reconstructive breast surgery. St Louis: Quality, 1990; 131292. McGrath MH, Burkhardt BR. The safety and

efficacy

of breast implants for augmentation mammoplasty. Plast Reconstr Sung 1984; 550-566.

14.

Cocke

\VMJr,

White

R IV, Vecchione

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Sampson W. Calcified capsule following augmentation mammoplasty. Ann Plast Sung 1985; 15:61-65.

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al

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