MRI screening for silicone breast implant rupture: accuracy, inter- and intraobserver variability using explantation results as reference standard

Ultrasound versus MRI for evaluation of silicone leakage from silicone breast implants

Background

Implant ruptures and gel bleed are not uncommon among women with silicone breast implants. While magnetic resonance imaging (MRI) is traditionally considered the gold standard diagnostic modality, recent studies suggest ultrasound might be an acceptable alternative. This study compares the efficacy of ultrasound and MRI in assessing implant integrity.

Methods

Women with silicone breast implants underwent a breast and axillary ultrasound and MRI on the same day. All tests were assessed by experienced radiologists. The accuracy, sensitivity, and specificity of ultrasound and MRI for implant rupture detection and silicone depositions in axillary lymph nodes were evaluated.

Findings

A total of 104 women participated in the study. The accuracy, sensitivity, and specificity of ultrasound for detecting implant ruptures compared to MRI were 96 %, 95 %, and 96 %, respectively. MRI demonstrated significantly lower sensitivity (44 %) for detecting silicone depositions in axillary lymph nodes compared to ultrasound. A significant association was observed between the presence of enlarged axillary lymph nodes and/or axillary pain and the detection of silicone depositions in axillary lymph nodes on ultrasound (χ2 (1, N = 104) = 5·1, p = 0·024). Six women exhibited silicone depositions in axillary lymph nodes despite having intact first-pair implants, indicative of gel bleed.

Interpretation

Ultrasound is nearly as effective as MRI for detecting breast implant ruptures and is superior for detecting silicone depositions in axillary lymph nodes. We therefore recommend initiating radiological examination in women with breast implants with a breast and axillary ultrasound, proceeding to MRI only if the ultrasound is inconclusive. The prevalence of gel bleed is understudied and its potential adverse health effects might be underestimated. Further research is needed to explore its potential association with development of systemic symptoms.

Imaging of the Reconstructed Breast

The incidence of breast cancer and, therefore, the need for breast reconstruction are expected to increase. The many reconstructive options available and the changing aspects of the field make this a complex area of plastic surgery, requiring knowledge and expertise. Two major types of breast reconstruction can be distinguished: breast implants and autologous flaps. Both present advantages and disadvantages. Autologous fat grafting is also commonly used. MRI is the modality of choice for evaluating breast reconstruction. Knowledge of the type of reconstruction is preferable to provide the maximum amount of pertinent information and avoid false positives. Early complications include seroma, hematoma, and infection. Late complications depend on the type of reconstruction. Implant rupture and implant capsular contracture are frequently encountered. Depending on the implant type, specific MRI signs can be depicted. In the case of myocutaneous flap, fat necrosis, fibrosis, and vascular compromise represent the most common complications. Late cancer recurrence is much less common. Rarely reported late complications include breast-implant-associated large cell anaplastic lymphoma (BIA-ALCL) and, recently described and even rarer, breast-implant-associated squamous cell carcinoma (BIA-SCC). In this review article, the various types of breast reconstruction will be presented, with emphasis on pertinent imaging findings and complications.

Silicone Breast Implant Rupture is More Prevalent in the Dominant Limb Side, A Retrospective Cohort Study

BACKGROUND

Breast implant rupture is associated with multiple risk factors such as implant age, manufacturer, and a history of trauma to the breast. However, the exact mechanism of breast implant rupture remains unclear. We hypothesize that repetitive minor mechanical forces on the implant collectively play a significant role in the cascade that eventually leads to its rupture. Therefore, we expect a more significant cumulative effect on the breast implant in the dominant upper limb side. Thus, we aim to ascertain whether laterality in silicone breast implant rupture is associated with the dominant upper limb.

METHODS

A retrospective cohort study was performed on patients with silicone breast implants who underwent an elective breast implant removal or exchange. All patients had breast augmentations for cosmetic reasons. We collected data on implant rupture laterality and limb dominance together with known risk factors like patient age, implant age, implant pocket, and implant volume.

RESULTS

A total of 154 patients with unilateral implant rupture were included in the study. Among patients with a dominant right limb (n = 133), an ipsilateral rupture was found in 77 patients (58%) (p = 0.036), while in patients with a left dominant limb (n = 21), an ipsilateral rupture was found in 14 patients (67%), (p = 0.036).

CONCLUSIONS

The dominant limb was a significant risk factor for ipsilateral breast implant rupture. The prevailing theory that cyclic envelope movement carries an increased rupture risk is reinforced in this study. Extensive prospective studies are needed to clarify risk factors for implant rupture further.

MRI for Evaluation of Complications of Breast Augmentation

Breast augmentation is one of the most common aesthetic procedures performed in the United States. Several techniques of breast augmentation have been developed, including the implantation of breast prostheses and the injection of autologous fat and other materials. The most common method of breast augmentation is to implant a prosthesis. There are different types of breast implants that vary in shape, composition, and the number of lumina. The rupture of breast implants is the leading cause of implant removal. The rupture rate increases substantially with the increasing age of the implant. Most implant ruptures are asymptomatic. Implant complications can be grouped into two categories: local complications in the breast and adjacent soft tissue, and systemic complications associated with rheumatologic or neurologic symptoms. The onset of local complications may be early (infection and periprosthetic collections including seromas, hematomas, or abscesses) or late (capsular contraction, implant rupture, gel bleed, or breast implant-associated anaplastic large cell lymphoma). Although mammography is the imaging modality for breast cancer screening, noncontrast breast MRI is the imaging modality of choice for evaluation of the integrity of breast implants and the complications of breast augmentation, for equivocal findings at conventional imaging, and as a supplement to mammography in patients with free injectable materials. The fifth edition of the Breast Imaging Reporting and Data System (BI-RADS) provides a systematic outline for MRI evaluation of patients with breast implants. Silicone- and water-selective sequences provide useful supplemental information to confirm intracapsular and extracapsular rupture. Breast MRI for evaluation of implant integrity does not require intravenous contrast material. The use of MRI contrast material in patients with breast augmentation is indicated when infection or malignancy is suspected. Radiologists should have a thorough understanding of the different techniques for breast augmentation, normal imaging features, and complications specific to breast augmentation. An invited commentary by Ojeda-Fournier is available online. ^©RSNA, 2022.

Topical silicone gel mistaken for a retained orbital foreign body on MRI

MRI is now a well-regarded imaging technique, but due to its use of strong magnetic fields, some metallic objects are contraindicated. We present a case of a man in his 40s with thyroid eye disease, who underwent bilateral orbital decompression. Following surgery, he was advised to start scar massage with topical silicone gel (Dermatix). He later underwent an MRI head scan which was halted due to concerns of a retained metallic foreign body. Topical silicone gel is widely used clinically for scar management. Due to its properties, it can cause the appearance of an artefact on MRI and be mistaken for a metallic foreign body. We present the first case to our knowledge of an MRI susceptibility artefact which was attributed to topical silicone gel and describe the diagnostic confusion it caused. We recommend asking patients to wash off any topical silicone gel before having an MRI scan.

Is breast ultrasound a good alternative to magnetic resonance imaging for evaluating implant integrity?

OBJECTIVE

To compare the diagnostic performance of breast ultrasound and breast magnetic resonance imaging and to correlate the findings on the two techniques that are suggestive of implant rupture.

MATERIAL AND METHODS

We reviewed the images and reports of breast ultrasound and magnetic resonance imaging studies done in our diagnostic and interventional breast imaging unit to evaluate breast implants in 205 patients between January 2015 and December 2017.

RESULTS

Ultrasound findings were compatible with implant rupture in 87 (42.4%) patients: intracapsular rupture in 44 (21.5%) and intracapsular and extracapsular rupture in 43 (21.0%). Ultrasound yielded 85.2% sensitivity, 89.7% specificity, 86.2% positive predictive value, and 89.0% negative predictive value. Magnetic resonance imaging findings were compatible with implant rupture in 88 (42.9%) patients: intracapsular rupture in 50 (24.4%) and intracapsular and extracapsular rupture in 38 (18.5%). The correlation between positive findings for the location of the rupture on the two imaging techniques was excellent (0.77; p<0.0001).

CONCLUSION

We found high concordance between the two techniques for the detection of intracapsular and extracapsular implant rupture. These results consolidate the use of ultrasound as the first-line imaging technique to evaluate implant integrity in our population; magnetic resonance imaging can be reserved for cases in which the ultrasound diagnosis of implant integrity is uncertain.

Silicone nipple discharge: A case report of an unusual presentation of breast implant rupture

INTRODUCTION

Breast implant rupture is a well-documented complication of breast implant surgery. Diagnosis of ruptured silicone implants can be difficult due to the lack of overt symptoms. This is the first reported case of a patient with silicone breast implant rupture presenting with clear nipple discharge and is presented in line with SCARCE 2018 Guidelines [1].

PRESENTATION OF CASE

A 45-year-old-female was referred to a breast surgeon with viscous clear nipple discharge, on a background of bilateral mastopexy-augmentation surgery 10 years prior. Imaging revealed extensive intraductal and free silicone causing significant stromal deformity secondary to breast implant rupture. Cytology of the nipple discharge was consistent with silicone gel. The patient was also found to have fibroadenoma without atypia in the right breast. She underwent an oncoplastic excision of free silicone and change of bilateral breast implants by a team of breast and plastic surgeons.

DISCUSSION

With breast implants being an increasingly common procedure worldwide, we can expect an increase in these unusual presentations. Clinicians and patients need to be aware of these in order to avoid an unnecessary delay in diagnosis.

CONCLUSION

Silicone implant rupture is a well-known complication and the rate of rupture increases over the life of the implant. Diagnosis of ruptured silicone implants is rare on clinical examination however remains an essential component of a doctor's examination of the patient and nipple discharge must be considered a symptom of rupture.

Sub-muscular plane for augmentation mammoplasty patients increases silicone gel implant rupture rate

BACKGROUND

Breast augmentation is one of the most common aesthetic procedures performed worldwide. One of the worst associated complications is implant rupture, a topic that will be addressed in the present study. The risk of developing silicone gel breast implant rupture following breast augmentation is associated with multiple factors, including: older generation implant, increased implant age, implant type, specific manufacturer, severe capsular contracture (Baker grade III or IV), and the presence of local symptoms. We hypothesize that the plane of the implant placement may also play a role in the development of implant rupture due to differences in opposing forces upon the implant between submuscular and subglandular planes.

OBJECTIVES

To assess the effect of potential risk factors on breast prosthesis rupture rate, focusing on implant pocket selection, capsular contracture and implant volume.

METHODS

A retrospective cohort study was performed on patients with silicone breast implants in either subglandular or submuscular plane, who underwent an elective breast implant exchange, with or without mastopexy, between January 2012 and June 2017. Data collected included patient's age, implant age, implant pocket, implant volume, capsular contracture grade, and implant status (ruptured or intact).

RESULTS

Data was collected on 362 women (700 breasts). A total of 284 women (542 breasts) met the inclusion criteria. The average age of the subjects was 43.4 ± 10.4 years. Average implant age during exchange was 10 ± 6.1. There was no difference between the characteristics of the submuscular group and the subglandular group, except from patient age. In a univariant analysis, patient's age (46.4 vs. 41.8, p < 0.001) and implant age (12.2 vs. 8.92 years, p < 0.001) were associated with significantly higher rupture rate. Among ruptured implants, the relative proportion of submuscular to subglandular implants was 64%, compared to 48% among non-ruptured implants (p < 0.0001). When controlling for potential confounders, submuscular pocket (OR = 0.1835, CI95% 1.25-2.69, p = 0.002) as well as implant size (OR = 1.004, CI95% 1.001-1.007, p = 0.005) were found to be a risk factor for implant rupture.

CONCLUSION

A sub-muscular implant pocket was identified as a significant risk factor for implant rupture. The prevailing theory that larger size implant carries an increased risk of complications, is also reinforced in this study. Large prospective studies are needed to further clarify risk factors for implant rupture.

Analysis of 109 Consecutive Explanted Breast Implants: Correlation Between Suspected Implant Rupture and Surgical Findings

INTRODUCTION

The use of breast implants is on the rise due to increases in breast reconstructive and aesthetic surgery. Implant rupture is a possible complication. Among assessment modalities for implant rupture detection, MRI is considered the gold standard.

METHODS

We conducted a prospective analysis of 57 women after breast augmentation or postmastectomy reconstruction (109 implants), admitted to our department between 2010 and 2015 due to suspected implant rupture. We correlated surgical findings with symptoms, physical examination, imaging, and device specifications.

RESULTS

Seventy-four explanted implants were preoperatively suspected as ruptured. Over a third were intact and unjustifiably explanted. MRI evaluation was the most accurate modality. Interestingly, 61 % of ruptured implants were left-sided. Patient's age, comorbidities, smoking, medications, presenting symptoms, implant duration, and volume did not correlate with implant rupture.

CONCLUSIONS

Our study confirmed preexisting data regarding the importance of imaging diagnosis, with MRI being the most accurate modality in both diagnosing and ruling out implant rupture. Interestingly, our study showed that MRI was accurate in detecting all intact implants, unlike lower detection rates reported in previous studies, thus preventing unnecessary explantation. Another unique finding was that the left-sided implants were significantly prone for rupture. As iatrogenic damage is the most common cause of implant rupture, with most surgeons being right-handed, awareness during surgery must be augmented, with further investigation required for potential causes of this unexpected difference. Our study emphasizes the importance of understanding the causes of rupture and the need for evidence-based indications regarding imaging and replacement of implants.

LEVEL OF EVIDENCE III

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 .

Diagnosis of ruptured breast implants through high-resolution ultrasound combined with real-time elastography

BACKGROUND

Implant rupture as a late complication of breast implant surgery is often a silent phenomenon that is difficult to diagnose. Sonoelastography is a new ultrasound-based technique that allows assessment of tissue elasticity.

OBJECTIVES

This study was undertaken to evaluate elastographic findings in normal and ruptured breast implants.

METHODS

This prospective study included 28 implants in 16 patients, all of whom underwent high-resolution ultrasound and real-time elastography. The diagnosis of implant rupture was confirmed by surgery.

RESULTS

Implant rupture was diagnosed in 5 out of 28 implants (17.9%). In those patients with ruptured implants, 3 had no symptoms, 1 presented with pain, and 1 complained of ipsilateral axillary lymph node swelling. Implants with a homogenous anechoic interior were considered to be intact. Ultrasound findings indicating implant rupture included multiple parallel echogenic lines in the implant interior in 2 cases and a mix of hyperechoic and hypoechoic masses in 3 cases. The feasibility of real-time elastography of implants was demonstrated in all cases. Elastograms of intact implants revealed a typical blue-green-red pattern familiar from cystic lesions. In all 5 ruptured implants, elastography revealed yellow-green figures without typical layering.

CONCLUSIONS

To the authors' knowledge this is the first series to combine high-resolution ultrasound with real-time elastography for the diagnosis of implant rupture. Since there are distinct differences between elastograms of intact and ruptured implants, addition of real-time elastography to conventional ultrasound may improve implant surveillance and obviate the need for magnetic resonance imaging.

The clinical implications of poly implant prothèse breast implants: an overview

Mammary implants marketed by Poly Implant Prothèse (PIP) were found to contain industrial grade silicone and this caused heightened anxiety and extensive publicity regarding their safety in humans. These implants were used in a large number of patients worldwide for augmentation or breast reconstruction. We reviewed articles identified by searches of Medline, PubMed, Embase, and Google Scholar databases up to May 2014 using the terms: "PIP", "Poly Implant Prothèse", "breast implants" and "augmentation mammoplasty" "siloxanes" or "silicone". In addition the websites of regulating bodies in Europe, USA, and Australia were searched for reports related to PIP mammary implants. PIP mammary implants are more likely to rupture than other implants and can cause adverse effects in the short to the medium term related to the symptoms of rupture such as pain, lumps in the breast and axilla and anxiety. Based on peer-reviewed published studies we have calculated an overall rupture rate of 14.5% (383/2,635) for PIP implants. However, there is no evidence that PIP implant rupture causes long-term adverse health effects in humans so far. Silicone lymphadenopathy represents a foreign body reaction and should be treated conservatively. The long-term adverse effects usually arise from inappropriate extensive surgery, such as axillary lymph node dissection or extensive resection of breast tissue due to silicone leakage.