Aesth Plast Surg (2014) 38:561–571 DOI 10.1007/s00266-014-0300-z

ORIGINAL ARTICLE

EXPERIMENTAL/SPECIAL TOPICS

Ultrasonography: A Useful Tool for Plastic Surgeons Jesu´s Benito-Ruiz • F. de Cabo

Received: 15 July 2013 / Accepted: 25 February 2014 / Published online: 19 March 2014  Springer Science+Business Media New York and International Society of Aesthetic Plastic Surgery 2014

Abstract Ultrasonography is a diagnostic technique used in many clinical specialties that should also be used by plastic surgeons. The authors have used ultrasonography since 2011 as part of the routine follow-up evaluation for all their patients who have undergone breast augmentation (the main indication), body implants, gynecomastia, fat transfer, or abdominoplasty. The main goal of this study was to correlate normal and pathologic conditions clinically with their respective imaging findings. The secondary aim was to establish the utility of this tool in a plastic surgery setting. With increasing experience, the use of ultrasound evaluation was expanded to include evaluation of seromas and hematomas, determination of the diastasis recti width, and confirmation of the presence of hernias, especially in patients with high adiposity, who are difficult to scan. This report describes several clinical cases of complications associated with breast augmentation and discusses the most significant common problems encountered during the first 2 years of ultrasonography scanner use in a plastic surgeon’s office. Level of Evidence V This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266.

J. Benito-Ruiz (&) Plastic Surgeon. Prı´vate Practice, Antiaging Group Barcelona, Clinica Tres Torres, c/ Dr Carulla 12 3rd floor, 08017 Barcelona, Spain e-mail: [email protected] F. de Cabo Specialist in Ultrasonography, CETIR, Barcelona, Spain

Keywords Ultrasonography  Breast implants  Implants  Follow-up  Plastic surgery

Introduction Ultrasound is an essential tool in medicine worldwide. Advances in the quality and reductions in the costs of ultrasound have greatly enhanced the use of this method, and it currently is used by physicians in many specialties. Ultrasonography is a virtual window into our patients, a tool that helps us to understand, verify, or rule out a disease. Ultrasound scans in plastic surgery require the use of high frequencies ([7.5 MHz) because they generate higher-resolution images. If greater penetration is desired, lower frequencies are required. The transducer used for ultrasound scans in plastic surgery is linear, resulting in rectangular images. Mode B and Doppler ultrasound are the most useful for plastic surgeons because they provide complementary information for diagnoses. Public health systems and private care companies usually do not cover the cost of ultrasound scans in plastic surgery, and most patients cannot afford to pay for them personally. A plastic surgeon may therefore use ultrasound as an auxiliary tool in clinical judgment, confirming and even solving potential problems in the office or deciding whether a patient requires further testing by other imaging methods or should be referred to another specialist. In our practice, the most important application of ultrasound has been for follow-up evaluation of patients who have received implants. This report describes several clinical cases of complications associated with breast augmentation and discusses the most significant common problems encountered during the first 3 years of ultrasonography scanner use in a plastic surgeon’s office.

123

562

Aesth Plast Surg (2014) 38:561–571

Fig. 1 Ultrasound of the breast showing the normal view of the different layers: skin, gland, pectoralis muscle, and implant. The implant appears as a hypoechogenic (black) mass surrounded by two hyperechogenic lines (the shell)

Materials and Methods The first author JB has routinely performed ultrasonography for clinical follow-up evaluation of all patients with breast augmentation since 2010. Exams have been performed before the surgical procedure and then 4 and 12 months afterward. Ultrasound Systems The following ultrasound systems were used for all the explorations: • •



Aloka ProSound SSD-4000 SV (Aloka, Tokyo, Japan) with a 10-MHz linear transducer Mindray M5 (Mindray, Shenzhen, China) with a multifrequency linear transducer, using frequencies of 10 to 12 MHz Mindray DP-2200 (Mindray, Shenzhen, China) with a linear transducer working at 7.5 MHz.

Normal and Pathologic Aspects of Implants A typical ultrasound image of an augmented breast shows several layers including the skin, subcutaneous tissue, mammary gland, retroglandular space (sometimes obliterated by pressure from the implant), the pectoral muscle (if the prosthesis is retropectoral), and the prosthesis itself (Fig. 1). Over time, a hyperechoic line surrounding the prosthesis appears, corresponding to the capsule. The cover of the prosthesis appears as two hyperechoic lines sandwiching a thin anechoic line (Fig. 2). A silicone implant appears as an anechoic mass (black), sometimes with artifactual images produced by reverberation of ultrasound,

123

depending on the resolution of the scanner or the density of the silicone. Ultrasound also can show the orientation marks of the anatomic prosthesis, which differ according to the implant brand. These marks appear as a change in the echogenicity (Fig. 2) or as thickenings (Fig. 3) in the cover of the prosthesis. Identifying these marks allows assessment of implant rotation with reference to the breast meridian. Should this occur, the seal, which usually is not visible because the posterior aspect of the implant is obscured and distorted due to the passage of the ultrasound through the prosthesis, becomes apparent.

Results Implant Rupture Clinical Case 1 A 47-year-old woman had surgery 25 years previously. She did not know the type or volume of her implants. Physical exploration results were normal, but routine ultrasound exploration showed signs of intracapsular rupture (Fig. 4), with no compromise of axillary nodes. These findings were confirmed by our echographist (Dr. de Cabo). The implants were removed (Figs. 5 and 6) and replaced with two Allergan (Allergan Inc, Irvine, California) TSM 330 implants (Fig. 7). Clinical Case 2 A 46-year-old woman underwent breast augmentation with Eurosilicone (Eurosilicone, Apt, France) round implants

Aesth Plast Surg (2014) 38:561–571

563

Fig. 2 Marks of a Natrelle (Allergan Inc, Irvine, California) anatomic, cohesive gel implant, which appear as a rupture of the shell’s continuity. It is very important not to confuse the marks with a cyst or rupture. They allow determination of whether an implant is properly positioned or not

Fig. 3 Transverse section of a lineal mark of a Polytech (Polytech, Dieburg, Germany) implant. It appears as a thickening of the shell

8 years previously (unknown volume). Ultrasound showed signs of right intracapsular rupture (Fig. 8) and snowstorm images suggesting silicone in her right axillary nodes (Fig. 9). The operation confirmed right implant rupture (Fig. 10). The implants were removed and replaced with Allergan MX290 (Allergan Inc, Irvine, California) prostheses, and five nodes were excised from the patient’s right axilla. Histopathologic analysis showed silicone in all five nodes.

signs of intra- and extracapsular bilateral rupture at the upper outer quadrant of her right breast (Fig. 11) and a snowstorm pattern in some right axillary nodes (Fig. 12). Both implants were removed (Fig. 13), as well as the right axillary nodes (4 of 7 positive for silicone), and replaced with two CUI (Allergan Inc, Irvine, California) round implants (CML295). Periareolar mastopexy was performed at the same time.

Clinical Case 3

Implant Rotation

A 38-year-old woman underwent breast augmentation with PIP implants (Poly Implant Prothese, La Seyne-sur-Mer, France) (365 mL) in 2008. She reported several months of discomfort in her right breast. Ultrasound showed evident

Clinical Case 4 A 35-year-old woman underwent surgery in 2009 (Fig. 14). We performed axillary subfascial breast augmentation with

123

564

Aesth Plast Surg (2014) 38:561–571

Fig. 4 Clinical case 1. Intracapsular rupture of an implant. There is silicone outside the shell (S), and the echogenic lines of the broken capsule are seen floating within the silicone, a sonographic correlate to the magnetic resonance imaging (MRI) linguini sign (sl)

Fig. 5 Intraoperative view of silicone gel removal in this patient through the axilla. Once the pocket is completely clean, a new implant is placed

Fig. 6 Syringes with silicone gel and the shell removed from the left breast

Hematomas Allergan (Allergan Inc, Irvine, California) implants (right MX445 and left MX410). Two years after the initial operation, the patient reported strange sensations in her left breast. The profile seemed to be slightly but not significantly flatter at the upper pole than in the control photo taken at 1 year (Fig. 15). Ultrasound confirmed that the seal of the implant was under the gland, indicating implant rotation (Fig. 16). The problem was solved by repositioning the implant and reducing the size of the pocket with internal capsulorrhaphy.

123

Although hematomas can be diagnosed only by their clinical signs and symptoms, ultrasound can be used to treat delayed hematomas and to determine whether a hematoma has been reabsorbed. The heterogeneity of the images can indicate the proportion of fibrin inside the hematoma and discern those areas more likely to be aspirated, as in the case illustrated in Fig. 17. With ultrasound, we can evaluate whether the collection is completely anechoic or not. The absence of echoes indicates that there

Aesth Plast Surg (2014) 38:561–571

is no organization of fibrin inside and that evacuating the hematoma should not be very difficult. However, echoes inside the collection mean clotting and solid areas and that drainage could be impossible to perform. Ultrasound allows us to identify the areas suitable to be aspirated.

565

Seromas Seroma appears as an anechoic mass between the tissue (gland or muscle) and the echoic lines of the shell. It is normal to find small seromas in the folds of the implants, but ultrasound is more interesting for the evaluation and treatment of seromas occurring mid- or long-term after the implantation.

Clinical Case 5 A 24-year-old woman underwent breast augmentation in 2010 with Polytech (Polytech, Dieburg, Germany) round 325-mL implants. Swelling of her left breast developed 3 years after this operation. Ultrasound showed a seroma (Fig. 18), and 120 mL of fluid was aspirated under ultrasound guidance. A second aspiration (150 mL) was performed 2 weeks after the initial procedure, and a catheter was placed (Figs. 19 and 20), both under ultrasound guidance. The catheter was removed 4 days later, and ultrasound follow-up assessment showed no recurrence (6 months at this writing).

Discussion

Fig. 7 Preoperative view of clinical case 1. Clinically, the breast shows no differences. Right: Postoperative view of a patient with Natrelle (Allergan Inc, Irvine, California) TSM 330 implants at 1 year

Breast implant rupture is a primary concern for both patients and surgeons. The incidence of silicone implant rupture is estimated to be 8 % in asymptomatic women and 33 % in symptomatic women [1]. The latest published data for Natrelle 410 (Allergan Inc, Irvine, California) (the

Fig. 8 Clinical case 2. Loss of the shell’s integrity with echogenic parallel lines, which are indicative for fragments of shell inside the implant (stepladder sign) and for loss of homogeneity of the echo signals within the implant

123

566

Aesth Plast Surg (2014) 38:561–571

Fig. 9 Axillary node with silicone. Echogenicity is increased, which obscures the tissue behind the node. This is suggestive for siliconome

Fig. 10 Implants removed. As diagnosed with ultrasound, the right implant was broken, and the left one was intact

implant used in the majority of patients at the first author’s clinic) is 6.4 % by subject and 3.8 % by implant [2]. For any given system for diagnosis, sensitivity, specificity, and negative and positive predictive values must be defined. Sensitivity measures the proportion of actual positive results correctly identified as such. Specificity measures the proportion of negative results correctly identified as such. Negative predictive value is defined as the proportion of subjects with a negative test result who have a correct diagnosis, and finally, positive predictive value is the proportion of positive test results that are truepositives such as correct diagnoses.

123

Physical exploration is unreliable for a diagnosis of rupture because it has only 30 % sensitivity [3]. Nuclear magnetic resonance imaging (MRI) is regarded as ideal for diagnosing implant ruptures [4, 5]. However, false-positives can occur because interpretation of these scans frequently depends on the experience of the specialist performing these tests. One study found that MRI had a sensitivity of 100 %, a specificity of 63 %, a positive predictive value (PPV) of 71 %, a negative predictive value (NPV) of 100 %, and an accuracy of 81 % in detecting breakage or leakage [4]. The ‘‘linguini sign’’ was found to have a sensitivity of 93 % and a specificity of 65 % in detecting breakage. In comparison, ultrasound had a sensitivity of 67 %, a specificity of 92 %, a PPV of 92 %, an NPV of 67 %, and an accuracy of 77 % in detecting breakage [6]. Another study reported that ultrasound had a sensitivity of 74 % and a specificity of 89 % [7]. A comparative study of 60 implants using MRI and ultrasound found that the respective sensitivities of clinical diagnosis, ultrasound, and MRI for rupture were 42 %, 50 %, and 83 % and that the respective specificities were 50 %, 90 %, and 90 %, with an 87 % agreement between ultrasound and MRI [8]. The main limitations of MRI are its cost and the fact that it cannot be used with claustrophobic patients, those implanted with a metal device, and patients of excess weight or height [9]. The U.S. Food and Drug Administration (FDA) has recommended that patients with breast implants should undergo an MRI every 2 or 3 years, beginning 10 years after implantation. Many patients, however, are noncompliant due to difficulties getting to the

Aesth Plast Surg (2014) 38:561–571

567

Fig. 11 Clinical case 3. Extracapsular rupture of the implant. The snowstorm pattern of the silicone is evident outside the shell. The snowstorm sign is characteristic of silicone present outside the implant, and it is pathognomonic for extracapsular rupture. Behind the siliconoma with its characteristic snowstorm pattern, it is not possible to distinguish any anatomic structures

Fig. 12 Several axillary nodes with the snowstorm pattern

center, the cost of MRI, or the risk of false-positives, which can lead to excessive surgeries. Chung et al. [1] demonstrated that screening of asymptomatic women with ultrasound followed by MRI screening for ultrasound-positive patients is the least expensive strategy for detecting silent ruptures. For the screening of symptomatic women, they recommended ultrasound alone as the optimal strategy. The use of ultrasound alone for symptomatic women is ideal because ultrasound detects extracapsular ruptures very well. These authors concluded that MRI is a costly screening technique

for breast implants that offered no benefit. This opinion is shared by other authors [8, 9]. Ultrasound sensitivity was found to be similar to the sensitivity of MRI but at a much lower cost [1, 7]. If ultrasound clearly shows an implant rupture (Fig. 11), no need exists for MRI. The main limitations of ultrasound are that it is operator dependent and can be difficult to interpret. Moreover, some signs such as the stepladder may appear in unbroken prostheses with a double lumen, leading to a misdiagnosis. Specialists in diagnostic imaging may not have sufficient experience with breast implants, thus requiring that these

123

568

specialists communicate directly with plastic surgeons. Such communication may be difficult in some work environments [10]. Plastic surgeons know about anatomy, surgical techniques, and the nature of implants. Proper training can establish correlations between clinical information and ultrasound images. Clearly, real-time ultrasound is much easier to interpret than static images. A study in a small series of patients showed diagnostic concordance among

Fig. 13 Implants removed. The ruptured implant has a slightly yellow and distorted appearance

Fig. 14 Clinical case 4. Preoperative (left) and postoperative (right) views 1 year after breast augmentation with Natrelle (Allergan Inc, Irvine, California) MX445 (right breast) and MX410 (left breast)

123

Aesth Plast Surg (2014) 38:561–571

MRI, ultrasound performed by a plastic surgeon, ultrasound performed by a sonographer, and surgical findings [11]. The signs of breakage we observed were similar to those reported previously [5], including loss of cover continuity, echogenic lines within the prosthesis (stepladder sign), heterogeneous aggregates inside the implant, and snowstorm signs in patients with extracapsular silicone near the ruptured implant or axilla. Snowstorm is a sign of extracapsular rupture, and no further imaging techniques are needed [1]. Double-lumen implants could give a falsepositive for breakage. However, we do not use these implants and have not had the opportunity of imaging a patient with such implants. In addition, ultrasound allows closer control of our patients in terms of clinical follow-up evaluation. It also enhances our ability to diagnose and even treat common problems, such as seroma. Although fluid can accumulate at any time after implant placement, the most interesting type of fluid accumulation is late seroma, which occurs for about 2 % of patients [12]. Ultrasound can be used to diagnose, locate, and treat seromas. For example, ultrasound can enable drainage of a seroma without damage to the implant or insertion of a catheter. Aspirations should be performed under aseptic conditions, enabling material to be collected for microbiologic and cytologic evaluations. Ultrasound, however, cannot be used to diagnose or treat an encapsulated seroma behind the implant. If one side is

Aesth Plast Surg (2014) 38:561–571

enlarged over the other and ultrasound does not show any periprosthetic fluid, confirmation requires an MRI or computed tomography (CT) scan.

Fig. 15 View 2 years after breast augmentation with anteroposterior rotation of the left implant. There are no significant changes in the frontal and profile views

569

The authors are currently working with the Spanish Association of Aesthetic Plastic Surgeons (AECEP), the Spanish Society for Aesthetic and Restorative Plastic Surgeons (SECPRE), and the Spanish Society of Ultrasound to develop guidelines and quality standards for ultrasound evaluation in plastic surgery. Training and accreditation from these societies will provide assurance of competency. The objectives are for surgeons and practitioners to be confident with ultrasound images and to be aware of common images linked to benign and malignant diseases they could discover when performing ultrasound. During the last 3 years, the first author (JB) has been routinely performing ultrasound for breast augmentation follow-up evaluation. As Bengston and Eaves [11] state, ultrasound is an extension of our physical evaluation. Many patients present with nonspecific pain or discomfort that has been attributed to implants by their gynecologists or general practitioners. Ultrasound diagnosis to determine whether the implants are broken or not avoids the removal of false-positive breakages. Capsular contracture and breakages are common concerns, and patients can be reassured by both physical evaluation and ultrasound evaluation. In some situations, such as capsular contracture Baker 3 or 4, knowing whether the implant is broken does not alter surgical planning, rendering ultrasound unnecessary. Calcifications of the capsule also can obscure the ultrasound exploration because they produce shadows behind them. This can significantly decrease the number of patients sent to radiologists for ultrasonography or MRI. If the clinician

Fig. 16 Ultrasound confirming that the seal of the implant (box) is just below the gland (a Natrelle implant in this case). The seal appears as a thickening of the shell. The sonographic appearance of the seal depends on the manufacturer

123

570

Aesth Plast Surg (2014) 38:561–571

Fig. 17 Postoperative hematoma after gynecomastia surgery. The extent of the hyperechogenic images within the fluid is an indication for the degree of fibrin content (clot) and for whether the fluid can be easily aspirated. The ‘‘C’’ indicates the two clots (hyperechogenic) that cannot be removed because they are solid. The asteriskshows the areas with different concentrations of fibrin, suggesting clotting. The plus signindicates the area in which drainage could be successful: the hypoechogenic area with some anechoic zones

Fig. 18 Clinical case 5. Late seroma. An anechoic fluid collection is seen above the echogenic parallel lines of the implant shell. Aspiration of the fluid can be performed under ultrasound guidance without inadvertently damaging the implant

has any doubt or suspicion about pathology in the breast, the patient should be referred to a specialist. If more information is required about implant integrity, an MRI should be performed. In conclusion, we believe that ultrasound should and will become a tool used by all plastic surgeons. As with any other technique or diagnostic tool, training is

123

important, and awareness of limitations essential, but ultrasound, as an office-based and surgeon-performed tool, enhances patient care. We recommend that surgeons attend a course on breast ultrasound, work closely with a specialist in breast ultrasound, and gain experience by performing ultrasound evaluations for all patients.

Aesth Plast Surg (2014) 38:561–571

571

Fig. 19 Catheter (arrow) placed in the space between the shell and the capsule under ultrasound guidance

4.

5. 6.

7. Fig. 20 Catheter placed in the inner quadrant of the left breast 8. Conflict of interest The authors declare that they have no conflicts of interest to disclose.

9.

10.

References 11. 1. Chung KC, Malay S, Shauver MJ, Kim HM (2012) Economic analysis of screening strategies for rupture of silicone gel breast implants. Plast Reconstr Surg 130:225–237 2. Maxwell GP, Van Natta BW, Murphy DK, Slicton A, Bengtson BP (2012) Natrelle style 410 form-stable silicone breast implants: core study results at 6 years. Aesthet Surg J 32:709–717 3. Holmich LR, Fryzek JP, Kjoller K et al (2005) The diagnosis of silicone breast-implant rupture: clinical findings compared with

12.

findings at magnetic resonance imaging. Ann Plast Surg 54:583–589 Ikeda D, Borofsky H, Herfkens RJ, Sawyer-Glover AM, Birdwell R, Glover GH (1999) Silicone breast implant rupture: pitfalls of magnetic resonance imaging and relative efficacies of magnetic resonance, mammography and ultrasound. Plast Reconstr Surg 104:2054–2062 Gorczyca DP, Sinha S, Ahn C et al (1992) Silicone gel breast implants in vivo: MR imaging. Radiology 185:407–410 Gorczyca DP, Gorczyca SM, Gorczyca KL (2007) The diagnosis of silicone breast implant rupture. Plast Reconstr Surg 120(Suppl 1):49S–61S Chung KC, Wilkins EG, Beil RJ et al (1996) Diagnosis of silicone gel breast implant rupture by ultrasonography. Plast Reconstr Surg 97:104–109 Hold PM, Alam S, Pilbrow WJ et al (2012) How should we investigate breast implant rupture. Breast J 18:253–256 Levine RA, Collins TL (1991) Definitive diagnosis of breast implant rupture by ultrasonography. Plast Reconstr Surg 87:1126–1128 Juanpere S, Perez E, Huc O, Motos N, Pont J, Pedraza S (2011) Imaging of breast implants: a pictorial review. Insights Imaging 2:653–670 Bengston BP, Eaves F III (2012) High-resolution ultrasound in the detection of silicone gel breast implant failure: background, in vitro studies, and early clinical results. Aesth Surg J 32:157–174 Spear SL, Rottman SJ, Glicksman C, Brown M, Al-Attar A (2012) Late seromas after breast implants: theory and practice. Plast Reconstr Surg 130:423–435

123

Ultrasonography: a useful tool for plastic surgeons.

Ultrasonography is a diagnostic technique used in many clinical specialties that should also be used by plastic surgeons. The authors have used ultras...
2MB Sizes 1 Downloads 2 Views