Normal Findings and Complications of Breast Implants.: Poster No.: Congress: Type: Authors

Normal findings and complications of breast implants.
Poster No.: C-1460

Congress: ECR 2017
Type: Educational Exhibit
Authors: I. FERNÁNDEZ SOBRINO, O. C. BENITEZ DUPIN, C.
ESCALONA HUERTA, M. PELAYO DELGADO, M. E. GIL
PINEDA, J. J. Cordones Guerrero; MADRID/ES
Keywords: Ultrasound, MR, CT, Breast, Complications, Education and training
DOI: 10.1594/ecr2017/C-1460
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Page 1 of 35
Learning objectives
The objetives are:
- To review the types of breast implants and their normal radiologic features.
- To describe the complications of breast implants in ultrasound, mammography and

magnetic resonance.
Background
Breast implants are common occurence in the daily job of a radiologist, as more and
more patients carry them, either for aesthetic or reconstructive purposes.
Breast implants are classified depending on the type of material of which they are fill,
the number of compartments and the surface contour (textured or smooth).
In terms of the type of material, breast implants can be filled with silicone gel, saline
solution or both.
Regarding the number of compartments, the most common breast implants are single
or double lumen:
- Single lumen: They are filled with silicone gel or, less frequently, with saline solution.
- Double lumen: The inner lumen is filled with silicone gel and the outer one with saline
solution.
- Reverse double lumen: The inner lumen is filled with saline solution and the outer one
with silicone gel.
On the other hand, according to the location on the breast, they are classified in ( Fig.
1 on page 3 ):
- Subglandular (retroglandular): In front of pectoralis major muscle.
- Subpectoral (retropectoral): Behind the pectoralis major muscle.
Page 2 of 35
Fig. 1: Retroglandular and retropectoral position of implants. Axial (A) and sagital (B)
T1-weighted MRI sequences showing the retroglandular position of bilateral silicone
gel-filled implants, which are entirely anterior to the pectoral muscles (arrows). Axial
(C) and sagital (D) T2-weighted MRI sequences showing the retropectoral position of
implants; the pectoral muscles are above the implants (arrowheads).
References: Department of Radiology, Hospital Fundación Jiménez Díaz / Madrid
2016
Images for this section:
Page 3 of 35
Fig. 1: Retroglandular and retropectoral position of implants. Axial (A) and sagital (B)
T1-weighted MRI sequences showing the retroglandular position of bilateral silicone gel-
filled implants, which are entirely anterior to the pectoral muscles (arrows). Axial (C) and
sagital (D) T2-weighted MRI sequences showing the retropectoral position of implants;
the pectoral muscles are above the implants (arrowheads).
© Department of Radiology, Hospital Fundación Jiménez Díaz / Madrid 2016
Page 4 of 35
Findings and procedure details
All breast implants, in the absence of complications, have radiological characteristics

defined in mammography, ultrasound and magnetic resonance.
1. Normal findings.
In a normal implant, you can find:
- Fibrous capsule: As a consequence of a physiological reaction to a foreign body, a

capsule of fibrous tissue is formed that surrounds the implant.
- Periprosthetic liquid: A small to moderate amount, which is reactive in nature.
- Radial folds: Infoldings of the shell into the silicone gel (or saline solution) that extend
perpendicularly inwards from the periphery, without presence of silicone between its
layers (unlike intracapsular rupture).
1.1. Ultrasound.
For the ultrasound evaluation of breast, a high frequency linear probe is used.
A normal implant is anechoic surrounded by a thin layer that corresponds to the fibrous
capsule ( Fig. 2 on page 20 ). The presence of small internal echoes or a sheet of
periprosthetic fluid are considered normal.
Page 5 of 35
Fig. 2: Normal breast implant on ultrasound: anechoic content, normal contour with
thin ecogenic line at the parenchyma tissue-implant interface.
2016
1.2. Mammography.
In mammography, breast implants are seen as rounded images of very high density (
Fig. 3 on page 21). They can overlap the mammary tissue and thus mask pathology.
Therefore, mammography is not used for breast studies with implants or its complications.
Page 6 of 35
Fig. 3: Normal findings of breast implants on mammography. Craniocaudal (A) and
mediolateral oblique (B) views: semiovoidea with smooth and well defined contours,
with an homogeneous dense content.
2016
1.3. Magnetic Resonance (MRI).
MRI is the technique of choice for the study of breasts with prosthetic implants.
The protocol includes T1-weighted images, T2-weighted images (silicone moderately
hyperintense, but less than water), silicone-only sequence (silicone hyperintense,
Page 7 of 35
water hypointense) and silicone-saturated sequence (water hyperintense, silicone
hypointense), with the advantage of performing volumetric reconstructions. Dynamic
sequences are added after administration of gadolinium if malignant or infectious disease
is suspected.
In MRI, normal implants are smooth in contour, surrounded by a hypointense ring in all
sequences corresponding to the fibrous capsule. Radial folds are best evaluated using
this technique, are considered normal findings and should not be confused with signs of
intracapsular rupture ( Fig. 4 on page 22).
Fig. 4: Normal silicone single lumen implant on MRI. Axial T2-weighted shows an
homogeneous high signal, smooth and well defined contour with an hipointense line
(A). Radial fold (B): single hypointense line extending inward from surface of implant
and ending blindly (arrow).
2016
2. Pathological findings.
2.1. Early Complications.
Early postoperative complications include seroma, hematoma and infection ( Fig. 5

on page 23). MRI and mammography may lead to suspicion of any of them, but
ultrasound is usually used as a more accessible and immediate technique, especially
Page 8 of 35
in view of suspected abscess. (Fig. 6 on page 24 shows the main characteristics of
each of them).
Fig. 5: Hematoma on ultrasound: irregular hypoechoic collection with internal septa

(arrow) adjacent to a breast implant.
2016
Page 9 of 35
Fig. 6: Early complications of breast implants.
2016
2.2. Late Complications.
The most common late postoperative complications are capsular contracture, implant
rupture, implant herniation and gel bleed; late seroma and breast implant-associated
lymphoma are rarer.
• Capsular Contracture:
This is the most commom complicaton of breast implants and it´s produced by an
abnormal constriction of the fibrous capsule. It has been associated more with single
lumen implants, retroglandular localization and a smooth cover. It can occur anytime
post-operatively, but usually within the first few months.
It is diagnosed clinically, by pain, tough texture and breast disfigurement. MRI and
ultrasound show an alteration of implant contour, which becomes irregular, asymmetrical
and more spherical in shape, (increased antero-posterior diameter) with infoldings and
thickening of the fibrous capsule (Fig. 7 on page 25).
Page 10 of 35
Fig. 7: Capsular contracture. Axial silicone-excited MRI sequences (A, B) and
ultrasound (C) shows irregular morphology with anomal folds and capsular thickening.
2016
• Implant Rupture:
MRI is the most sensitive and specific technique for the diagnosis of implant rupture. The
estimated incidence rate is 2 cases / 100 implants / year. The factors most related to
prosthesis rupture are the location and time of the implant, with a mean age of rupture
of 10.8 years.
Mammography is the least sensitive technique for diagnosis (S 11-69%) because it does
not identify intracapsular ruptures. Ultrasound also has low sensitivity and specificity for
its diagnosis because it is limited to assess the posterior wall of the prosthesis.
Page 11 of 35
Implant rupture can be classified as intracapsular or extracapsular rupture:
A) Intracapsular Rupture:
They represent 77-89% of the implants rupture. They are produced by the rupture of the
shell, remaining intact the fibrous capsule.
· Ultrasound signs (Fig. 8 on page 26):
- Increased space with isoechoic silicone between the fibrous capsule and the implant
surface
- "Stepladder" sign: Multiple curvilinear lines in the interior of the implant at various levels
which correspond to the collapsed shell (correlates with linguine sign on MRI).
- Irregular contour of breast implant
- Low-level echoes within the implant
Fig. 8: Ultrasound of intracapsular rupture. Echogenic fluid (asterisk) between the

capsule and the shell (A). Stepladder sign (B): curvilinear lines in the interior of the
implant (arrows).
2016
· MRI signs:
Page 12 of 35
- "Teardrop" sign (Fig. 9 on page 27): Focal invagination of the membrane with a drop
of silicone between the two sheets of the membrane (unlike the radial folds, which have
no silicone between the two membrane sheets).
- "Keyhole" sign: Invagination of the membrane with silicone along the entire space that
form the two sheets of the membrane (they not touching each other).
Fig. 9: Intracapsular rupture. "Teardrop" sign on axial silicone-excited MRI sequences.

2016
Page 13 of 35
- Subcapsular line sign: A hypointense line parallel to the fibrous capsule due to a thin
layer of silicone placed between the shell and the fibrous capsule
- "Linguini" sign ( Fig. 10 on page 28 ): Curvilinear hypointense lines, which represents

the collapsed shell, floating inside the high-signal intensity silicone gel. It is the most
reliable sign for the diagnosis, but is only present when the membrane collapses.
- "Droplet" sign ( Fig. 11 on page 29 ): Changes in the signal intensity of the silicone
gel. In the case of the double lumen implant, it is due to the presence of saline drops
floating inside the silicone gel.
Fig. 10: Intracapsular rupture. Axial T2-weighted MRI sequences (A, B). "Linguini"
sign (arrows): multiple curvilinear low-signal intensity lines floating in the high-signal
intensity silicone gel. "Droplet" sign (arroheads): small hyperintense saline drops within
the implant.
2016
Page 14 of 35
Fig. 11: Intracapsular rupture. Axial T2-weighted (A) and axial silicone-supression (B)
MRI sequences with changes in the signal intensity of the silicone gel (arrows).
2016
B) Extracapsular Rupture:
It is defined as rupture of the shell and the fibrous capsule, with silicone leakage beyond
the fibrous capsule into the surrounding tissues.
· Mammography signs: Radiopaque material outside the prosthesis, into the breast
parenchyma, the pectoral muscle or within the axillary lymph nodes.
· Ultrasound signs:
- Siliconomas: hypoechogenic or anechogenic nodules formed by fibrous tissue that

surrounds the silicone.
In cases in which liquid silicone is injected, masses of silicone are formed, which on
ultrasound form the sign called "in snowstorm", with a conglomeration of hypoechoic
nodules or a mass with dirty posterior shadowing, formed by silicone surrounded by tissue
of granulation due to foreign- body reaction. The presence of liquid silicone prevents the
diagnosis of a possible extracapsular rupture ( Fig. 12 on page 29 ).
Page 15 of 35
Fig. 12: Siliconomas. Two different patiens with a history of liquid silicone breast
injections. Craniocaudal view mammogram (A, B) with nodules multiple large, well-
circumscribed and partially calcified masses. Breast ultrasound showing an echogenic
mass (C) and nodules (D) with dirty posterior shadowing, termed the "snowstorm" sign.
2016
· MRI signs ( Fig. 13 on page 30 ):
- Free silicone: Identical signal intensity as the silicone gel inside the implant. With time,
silicone granuloma formation may occur, showing enhancement that may mimic breast
carcinoma.
- Infiltrated lymph nodes.
Page 16 of 35
Fig. 13: Extracapsular and intracapsular rupture. Axial T2-weighted (A) and silicone-
excited (B) MRI sequences. Isointense extracapsular silicone (arrows) lateral to the
right breast implant consistent with extracapsular rupture implant. "Teardrop" sign
(arrowheads) consistent with intracapsular rupture.
2016
• Implant Herniation
It is the protrusion of the implant shell through a focal weakness of the fibrous capsule,
which causes a lobulation in the contour of the implant. Sometimes it is difficult to
differentiate it from implant rupture ( Fig. 14 on page 31 ). It is called the "rat-tail sign"
if very pronounced.
Page 17 of 35
Fig. 14: Herniation and intracapsular rupture. Axial (A, B) and sagital (C) silicone-
excited MRI sequences. Herniation with protrusion of the shell through focal defect
of the capsule (arrows). Changes in the signal intensity of the silicone gel due to
intracapsular rupture (arrowheads).
2016
• Gel Bleed
It is produced by the transudation of the silicone fluid (rather than the gel) through the
micropores of the intact implant shell. The fluid can migrate to the other parts of the body
(regional lymph nodes). A small amount is considered normal, although some authors
consider it an early sign of intracapsular rupture. With the new cohesive silicone gel
implants, this phenomenon is improved.
• Late Seroma
Unlike the postoperative seroma, late seroma is a rare complication. It is defined as the
increase of intracapsular periprosthetic fluid past post-surgical time (from 3 months from
surgery), without the presence of trauma or other triggers ( Fig. 15 on page 31 ). It
is associated with a textured cover and, although most are idiopathic, it is important to
Page 18 of 35
bear in mind that it has been associated with malignant pathology (Anaplastic Large Cell
Lymphoma), which is why its cytological study is fundamental.
Fig. 15: Late seroma. Axial (A) and sagital (B) T2-weighted MRI sequences showing
periprosthetic collection with high signal intensity in the left breast (asterisks). Axial
T1 with fat and silicone-supression (C) showing seroma with low signal intensity. The
silicone implant is intact, showing radial fold (arrows).
2016
• Anaplasic Large Cell Lymphoma (ALCL)
ALCL is a rare type of non-Hodgkin lymphoma , described almost exclusively in women

with breast implants (it`s very rare in women without breast implants).
ALCLs associated with prostheses have a characteristic immunohistochemical profile

(CD30 + and ALK- T cells) and it arises from the fibrous capsule of the prosthesis, unlike
the primary neoplasias that arise from breast parenchyma. The most common signs are
Page 19 of 35
unilateral inflammation and edema due to the formation of a late periprosthetic seroma,
but the development of nodules or masses in the fibrous capsule are rarer ( Fig. 16 on
page 32 ).
Fig. 16: Anaplasic Large Cell Lymphoma in women with breast implants. Ultrasound
showing hipoecoic nodule (arrow) in contact with de capsule of the implant breast
(asterisks) (A) and another hipoecoic mass in contact with the pectoral muscle
(arrowheads) (B). Axial T1-weight MRI sequence (C) and a detail of C (D) showing a
hipointense masse in the superointernal quadrant of left breast which infilitring pectoral
muscle.
2016
Images for this section:
Page 20 of 35
Fig. 2: Normal breast implant on ultrasound: anechoic content, normal contour with thin
ecogenic line at the parenchyma tissue-implant interface.
Page 21 of 35
Fig. 3: Normal findings of breast implants on mammography. Craniocaudal (A) and
mediolateral oblique (B) views: semiovoidea with smooth and well defined contours, with
an homogeneous dense content.
Page 22 of 35
Fig. 4: Normal silicone single lumen implant on MRI. Axial T2-weighted shows an
homogeneous high signal, smooth and well defined contour with an hipointense line (A).
Radial fold (B): single hypointense line extending inward from surface of implant and
ending blindly (arrow).
Page 23 of 35
Fig. 5: Hematoma on ultrasound: irregular hypoechoic collection with internal septa
(arrow) adjacent to a breast implant.
Page 24 of 35
Fig. 6: Early complications of breast implants.
Page 25 of 35
Fig. 7: Capsular contracture. Axial silicone-excited MRI sequences (A, B) and ultrasound
(C) shows irregular morphology with anomal folds and capsular thickening.
Page 26 of 35
Fig. 8: Ultrasound of intracapsular rupture. Echogenic fluid (asterisk) between the
capsule and the shell (A). Stepladder sign (B): curvilinear lines in the interior of the implant
(arrows).
Page 27 of 35
Fig. 9: Intracapsular rupture. "Teardrop" sign on axial silicone-excited MRI sequences.
Page 28 of 35
Fig. 10: Intracapsular rupture. Axial T2-weighted MRI sequences (A, B). "Linguini"
sign (arrows): multiple curvilinear low-signal intensity lines floating in the high-signal
intensity silicone gel. "Droplet" sign (arroheads): small hyperintense saline drops within
the implant.
Fig. 11: Intracapsular rupture. Axial T2-weighted (A) and axial silicone-supression (B)
MRI sequences with changes in the signal intensity of the silicone gel (arrows).
Page 29 of 35
Fig. 12: Siliconomas. Two different patiens with a history of liquid silicone breast
injections. Craniocaudal view mammogram (A, B) with nodules multiple large, well-
circumscribed and partially calcified masses. Breast ultrasound showing an echogenic
mass (C) and nodules (D) with dirty posterior shadowing, termed the "snowstorm" sign.
Page 30 of 35
Fig. 13: Extracapsular and intracapsular rupture. Axial T2-weighted (A) and silicone-
excited (B) MRI sequences. Isointense extracapsular silicone (arrows) lateral to the
right breast implant consistent with extracapsular rupture implant. "Teardrop" sign
(arrowheads) consistent with intracapsular rupture.
Fig. 14: Herniation and intracapsular rupture. Axial (A, B) and sagital (C) silicone-excited
MRI sequences. Herniation with protrusion of the shell through focal defect of the capsule
(arrows). Changes in the signal intensity of the silicone gel due to intracapsular rupture
(arrowheads).
Page 31 of 35
Fig. 15: Late seroma. Axial (A) and sagital (B) T2-weighted MRI sequences showing
periprosthetic collection with high signal intensity in the left breast (asterisks). Axial T1
with fat and silicone-supression (C) showing seroma with low signal intensity. The silicone
implant is intact, showing radial fold (arrows).
Page 32 of 35
Fig. 16: Anaplasic Large Cell Lymphoma in women with breast implants. Ultrasound
showing hipoecoic nodule (arrow) in contact with de capsule of the implant breast
(asterisks) (A) and another hipoecoic mass in contact with the pectoral muscle
(arrowheads) (B). Axial T1-weight MRI sequence (C) and a detail of C (D) showing a
hipointense masse in the superointernal quadrant of left breast which infilitring pectoral
muscle.
Page 33 of 35
Conclusion
Given the increase of patients carrying breast implants, the radiologist should be familiar
with the normal characteristics of these in different imaging techniques, and should also
be able to recognize potential immediate and late complications.
Personal information
I. Fernández Sobrino. Department of Radiology, Fundación Jiménez Díaz, Madrid.
O. Benítez Dupin. Department of Radiology, Fundación Jiménez Díaz, Madrid.
C. Escalona Huerta. Department of Radiology, Fundación Jiménez Díaz, Madrid.
M. Pelayo Delgado. Department of Radiology, Fundación Jiménez Díaz, Madrid.
M.E. Gil Pineda. Department of Radiology, Fundación Jiménez Díaz, Madrid.
J.J. Cordones Guerrero. Department of Radiology, Fundación Jiménez Díaz, Madrid.
References
Wong T& Wan L, Fung PY et al. Magnetic resonance imaging of breast augmentation:
a pictorial review. Insights Imaging 2016; 7:399-410
Kwek JW. Gel-Gel Double-Lumen Silicone Breast Implant: Mimic of Intracapsular Implant
Rupture. AJR 2006; 187:W436-W437
Brown SL, Middleton MS, Berg WA, Soo MS, Pennello G. Prevalence of rupture of
silicone gel breast implants revealed on MR imaging in a population of women in
Birmingham, Alabama. AJR 2000; 175:1057-1064
Page 34 of 35
Hölmich LR, Vejborg I, Conrad C, Sletting S, McLaughlin JK. The diagnosis of breast
implant rupture: MRI findings compared with findings at explantation. European Journal
of Radiology 2005;53:213-225
Yang N, Muradali D. The Augmented Breast: A Pictorial Review of the Abnormal and
Unusual. AJR 2011; 196:W451-W460
Middleton MS and McNamara MP Jr. Breast Implant Classification with MR Imaging

Correlation. Radiographics. 2000;20:1-72 (online only).
Berg WA et al. MR Imaging of Extracapsular Silicone from Breast Implants: Diagnostic

Pitfalls. AJR 2002;178:465-472
Juanpere S, Perez E, Motos N, Pont J, Pedraza S. Imaging of breast implants-a pictorial

review. Insights Imaging 2011;2:653-670
Jewell M, Spear SL, Largent J, et al. Anaplastic Large T-Cell Lymphoma and Breast
Implants: A Review of the Literature. Plast. Reconstr. Surg. 2011; 128: 651-661
Clemens MW, Miranda RM Breast Implant-Associated Anaplastic Large Cell Lymphoma

After 18 Years of Investigation. Clin Plastic Surg 2015; 42: 605-613
Page 35 of 35

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Normal findings and complications of breast implants.

Poster No.: C-1460

The objetives are:

- To describe the complications of breast implants in ultrasound, mammography and

- Subglandular (retroglandular): In front of pectoralis major muscle.

- Subpectoral (retropectoral): Behind the pectoralis major muscle.

Images for this section:

© Department of Radiology, Hospital Fundación Jiménez Díaz / Madrid 2016

All breast implants, in the absence of complications, have radiological characteristics

In a normal implant, you can find:

- Fibrous capsule: As a consequence of a physiological reaction to a foreign body, a

- Periprosthetic liquid: A small to moderate amount, which is reactive in nature.

1.3. Magnetic Resonance (MRI).

2.1. Early Complications.

Early postoperative complications include seroma, hematoma and infection ( Fig. 5

Fig. 5: Hematoma on ultrasound: irregular hypoechoic collection with internal septa

2.2. Late Complications.

· Ultrasound signs (Fig. 8 on page 26):

- Irregular contour of breast implant

- Low-level echoes within the implant

Fig. 8: Ultrasound of intracapsular rupture. Echogenic fluid (asterisk) between the

Fig. 9: Intracapsular rupture. "Teardrop" sign on axial silicone-excited MRI sequences.

- "Linguini" sign ( Fig. 10 on page 28 ): Curvilinear hypointense lines, which represents

- Siliconomas: hypoechogenic or anechogenic nodules formed by fibrous tissue that

· MRI signs ( Fig. 13 on page 30 ):

- Infiltrated lymph nodes.

• Anaplasic Large Cell Lymphoma (ALCL)

ALCL is a rare type of non-Hodgkin lymphoma , described almost exclusively in women

ALCLs associated with prostheses have a characteristic immunohistochemical profile

Images for this section:

© Department of Radiology, Hospital Fundación Jiménez Díaz / Madrid 2016

© Department of Radiology, Hospital Fundación Jiménez Díaz / Madrid 2016

© Department of Radiology, Hospital Fundación Jiménez Díaz / Madrid 2016

© Department of Radiology, Hospital Fundación Jiménez Díaz / Madrid 2016

© Department of Radiology, Hospital Fundación Jiménez Díaz / Madrid 2016

© Department of Radiology, Hospital Fundación Jiménez Díaz / Madrid 2016

© Department of Radiology, Hospital Fundación Jiménez Díaz / Madrid 2016

© Department of Radiology, Hospital Fundación Jiménez Díaz / Madrid 2016

© Department of Radiology, Hospital Fundación Jiménez Díaz / Madrid 2016

© Department of Radiology, Hospital Fundación Jiménez Díaz / Madrid 2016

© Department of Radiology, Hospital Fundación Jiménez Díaz / Madrid 2016

© Department of Radiology, Hospital Fundación Jiménez Díaz / Madrid 2016

© Department of Radiology, Hospital Fundación Jiménez Díaz / Madrid 2016

© Department of Radiology, Hospital Fundación Jiménez Díaz / Madrid 2016

© Department of Radiology, Hospital Fundación Jiménez Díaz / Madrid 2016

I. Fernández Sobrino. Department of Radiology, Fundación Jiménez Díaz, Madrid.

O. Benítez Dupin. Department of Radiology, Fundación Jiménez Díaz, Madrid.

C. Escalona Huerta. Department of Radiology, Fundación Jiménez Díaz, Madrid.

M. Pelayo Delgado. Department of Radiology, Fundación Jiménez Díaz, Madrid.

M.E. Gil Pineda. Department of Radiology, Fundación Jiménez Díaz, Madrid.

J.J. Cordones Guerrero. Department of Radiology, Fundación Jiménez Díaz, Madrid.

Middleton MS and McNamara MP Jr. Breast Implant Classification with MR Imaging

Berg WA et al. MR Imaging of Extracapsular Silicone from Breast Implants: Diagnostic

Juanpere S, Perez E, Motos N, Pont J, Pedraza S. Imaging of breast implants-a pictorial

Clemens MW, Miranda RM Breast Implant-Associated Anaplastic Large Cell Lymphoma

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