Sonography of the Breast Part III Module 9 Breast Augmentation Harry H. Holdorf PhD, MPA, RDMS (Ab, Ob/Gyn, Br), RVT, LRT(AS)

Module Nine- Breast Augmentation

Breast Implants Breast implants are used to: Reconstruct the breast after surgical mastectomy Correct congenital or traumatic deformities Increase or remodel the breast for cosmetic reasons While the psychological benefits are widely acknowledged, both silicone and saline breast implants are not without complications and controversy.

Types of Implants There are many types of breast implants. Most are filled with saline, silicone gel, a combination of saline gel, a combination of saline and silicone, or the new cohesive implant (“gummy bear” implant). More than 100 varieties have been produced. As a sonographer, it is important to understand the type of implant being imaged to offer an accurate diagnosis. Various types include: Single lumen- silicone or saline Double lumen – inner silicone, outer saline Reverse double lumen –inner saline, outer silicone Smooth or textured surface Expandable implant (expander valve may be visible.

Saline implants are slightly more transparent than silicone on mammography : Saline implant on Mammography

Silicone implant on Mammography

Implant placement Breast implants may be surgically placed in one of two areas: Subglandular – posterior to the parenchymal layer and anterior to the pectoralis muscles. Subpectoral – posterior to the pectoralis major muscle

Subglandular implant

Subpectoral implant

Imaging implants Special Mammography technique with significantly lighter compression may be used to evaluate patients with breast implants. Lighter compression, however, limits the diagnostic ability of screening patients for early cancer. Special views may also be performed such as the Eklund (Implant Displaced – ID) views. Mammography is capable of detecting silicone leakage and saline collapse, but it is relatively insensitive compared to MRI and sonography.

Implant Displaced (ID) views

The Eklund technique The Eklund technique has been devised for performing mammography on women with breast implants. This technique is called the “displacement view”. The displacement procedure normally involves pushing the implant back and pulling tissue into the view so that it can be compressed and mammograms can then be taken.

Standard Mammography views are taken first Standard Mammography views are taken first. The breast and implant are compressed with moderate force.

Image displacement mammography views (also called Eklund views) are preformed with the implant pushed back against the chest wall. The compression paddle is applied to the breast tissue which is pulled forward.

Mammography of both breasts (CC views) without Eklund technique showing normal breast implants

Silicone rupture of left breast - mammogram

Magnetic Resonance Imaging (MRI) is the most accurate imaging modality in the detection of implant rupture. It is extremely effective in assessing the integrity of the implant and nearly all complications.

Normal Silicone Implant on MRI

Sonography Sonography Provides excellent evaluation of the augmented breast. It is effective in examining the existing breast tissue surrounding the implant for disease and also the implant for complications Sonography misses malignant masses in patients with implants INFREQUENTLY.

On Sonography: Both saline and silicone gel implants have an anechoic internal appearance. Single lumen implants appear large, oval, and anechoic The inner bag of a double lumen implant is occasionally identified (not consistently) On close inspection of the anterior tissue/implant interface, 3 horizontal echogenic areas may be appreciated. These represent: Fibrous capsule – most anterior Anterior surface of the implant (entrance echo of the elastomer shell) Posterior surface of the implant (exiting echo of the shell)

Artifacts Artifacts form implants are relatively common on sonography. Therefore, the sonographer should be able to identify normal artifacts and differentiate them from complications. Reverberation: Reverberation artifacts are common along the anterior surface of the implant. This can present a challenge when attempting to differentiate intracapsular rupture. Speed Error The speed of sound through silicone is much slower (approximately ½ the speed) than through soft tissue. Therefore, the posterior wall of the silicone implant appears much deeper in the chest wall than the surrounding tissue. This artifact is not a problem with saline implants.

Complications Since the US food and Drug Administration limited the use of silicone implants in April of 1992, complications due to breast implants have been heavily investigated. Implant rupture and silicone leakage have become the main focus of the investigation and sonography and MRI have played a critical role. Once an implant is surgically inserted, a fibrous capsule of connective tissue usually forms around the implant. This is a reaction of the breast tissue to the implant. This capsule creates a barrier and helps define intracapsular versus extracapsular ruptures.

Signs and symptoms of Implant Rupture include: Change in appearance, shape and consistency of the breast Hardening of the breast Tenderness or burning sensation Breast lump Autoimmune diseases have been suggested (including Rheumatoid arthritis) Old implant (average age of rupture is 13 years)

Complications of Implants: Hematoma Abscess Migration of the implant Partial or total collapse Silicone gel bleed Capsular Contracture The implant becomes fixed in the breast due to fibrosis Causes the breast to become hard and painful May cause a Radial fold Radial folds represent a folding or outside compression of the implant Implant rupture A Gel Bleed is the escape of silicone into the surrounding tissue with an intact (non-ruptured) implant.

FIN