Clinical Radiology 68 (2013) 851e858

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Clinical Radiology
journal homepage: www.clinicalradiologyonline.net

Pictorial Review

The sonographic appearances of breast implant rupture

E. Lake, S. Ahmad, R. Dobrashian*
Breast Screening Unit, East Lancashire Hospitals NHS Trust, UK

art icl e i nformat ion

Implant rupture is a common late complication of breast implant procedures. Ruptures are
Article history: often silent and difficult to diagnose clinically. This review demonstrates normal appearances
Received 2 January 2013 and sonographic signs of implant rupture. Breast sonologists should be aware of these signs
Received in revised form and pitfalls in interpretation when imaging breast implants.
7 March 2013 Ó 2013 The Royal College of Radiologists. Published by Elsevier Ltd. All rights reserved.
Accepted 14 March 2013

Introduction technology has improved with 8e10 year rupture rates of

An estimated 10,000 women in the UK underwent breast
implant surgery in 2011. Breast implant insertion is usually
carried out during reconstructive surgery following breast
cancer treatment or as a breast augmentation procedure for
cosmetic reasons. Possible complications of breast implants
include: capsular contraction, implant rupture, gel bleed,
scarring, creasing and folding, and change in nipple sensi-
tivity.1 Of these complications implant rupture is the most
significant and the most common indication for implant
removal.2 This review demonstrates normal appearances
and sonographic signs of implant rupture, which the breast
sonologist should be aware of when imaging breast im-
plants. All of the images presented in this review are of
implants subsequently proven at surgery to have been
ruptured.
Breast implant rupture
Older studies have reported implant rupture rates of up
to 50% at 12 years.3 However, it is clear that reported
rupture rates have significantly decreased as implant
* Guarantor and correspondent: R. Dobrashian, East Lancashire Breast
Screening Service, Edith Watson Unit, Burnley General Hospital, Casterton
Avenue, Burnley BB10 2PQ, UK. Tel.: þ44 01282 805301.
E-mail address: Richard.Dobrashian@elht.nhs.uk (R. Dobrashian).
some more modern devices between 10% and 14%.4
Symptoms of implant rupture are very varied and non-
specific. These symptoms include chest wall pain, burning
pain in the breast, redness, inflammation, altered implant
shape, generalized lumpiness, and an axillary mass.
However, many implant leakages are silent, causing no
symptoms whatsoever.3
PIP implants
In 2010, it was revealed that the French company PIP
(Poly Implant Prothe se) had been using industrial-grade
silicone instead of medical-grade silicone filler inside their
implants. This caused a global health scare. It has since been
shown that these implants have an increased premature
rupture and subsequent leakage rate.5
Since the PIP scandal, we have seen a large increase in
numbers of patients being referred for imaging to investi-
gate the integrity of their breast implants. The Department
of Health Expert Group led by Sir Bruce Keogh advised:
“All providers of breast implant surgery should contact
any woman who has or may have PIP implants d if they
have not already done so d and offer her a specialist
consultation and any appropriate investigation to
determine if the implants are still intact; if the original
provider is unable or unwilling to do this, a woman
should seek referral through her GP to an appropriate

0009-9260/$ e see front matter Ó 2013 The Royal College of Radiologists. Published by Elsevier Ltd. All rights reserved.
http://dx.doi.org/10.1016/j.crad.2013.03.014
852 E. Lake et al. / Clinical Radiology 68 (2013) 851e858

specialist; if there is any sign of rupture, she should be
offered an explanation; if the implants still appear to be
intact she should be offered the opportunity to discuss
with her specialist the best way forward.”6
How should we investigate breast implant
rupture?
There are differing bodies of opinion as to the optimum
method of imaging to identify signs of rupture. Breast
magnetic resonance imaging (MRI) has long been consid-
ered the reference standard imaging method to radiologi-
cally identify implant rupture with reported sensitivity of
72e94% and specificity of 85e100%.7 However, MRI is time-
consuming, costly, and often uncomfortable for the patient.
More recently the consensus for imaging patients with
breast implants has moved towards an approach whereby
ultrasound is used as a first-line investigation and MRI used
for problem-solving in more complex cases.8,9 This
approach is also supported by economic evaluation.10
Several sonographic signs of implant rupture have been
documented in the literature in the past with overall sen-
sitivities and specificities close to that of MRI in some
series.11e13 These series have concentrated on demon-
strating the collapsed implant membrane “stepladder” sign,
low-level echoes within the implant, and the “snowstorm”
sign of extra-capsular silicone.
Normal breast implant anatomy
Many variations of implant exist but by far the most
common type in Europe is a single lumen with silicone
filler.14 Shell construction differs between manufacturers,

Figure 1 Sonograms of normal implants. (a) Two echogenic lines representing the implant outer shell (A) and the surrounding fibrous
capsule (B). (b) A more complex multi-layered shell wall represented by multiple echogenic lines (C). (c) Normal implant folds. (d) Reverberation
artefact seen in the superficial part of the implant.
 E. Lake et al. / Clinical Radiology 68 (2013) 851e858 853

Figure 2 (a) Appearance of debris within a normally anechoic implant, a sign of denaturation of silicone and early implant rupture this
appearance may become confluent affecting the majority of the implant (b).

becoming increasingly complex in an effort to reduce the
movement of microscopic amounts of silicone through the
implant into the surrounding tissues known as “gel bleed”.
To this end, most modern implants contain a low perme-
ability layer as part of the shell. This is distinctly different to
the previously used double-lumen implants, which con-
tained two separate lumens, usually one being saline, which
could be inflated to size. After implantation a fibrous
capsule develops around the implant.
Technique
quadrants of the breast should be imaged with special
attention paid to the implant edge and folds. In addition to
the breast itself, the sonologist should image deep to the
lateral fibres of the pectoralis major muscle and the axilla to
look for silicone in the lymph nodes. In the presence of
bilateral implants when imaging a single symptomatic side,
the asymptomatic side should also be imaged due to the
high rates of silent rupture.
Sonographic appearances of the normal
breast implant

We advocate the use of a high-frequency linear probe The normal sonographic appearances of a breast implant
(12þ MHz) optimized to the depth of the implant. All four demonstrate three intact echogenic layers representing the

Figure 3 (a) Sonogram demonstrating the “stepladder” sign, multiple discontinuous lines (A) within the implant representing folds of collapsed
implant shell. (b) A T2-weighted MRI image of the “linguine sign” of implant rupture.
854 E. Lake et al. / Clinical Radiology 68 (2013) 851e858

Figure 4 (a) Sonogram showing a disruption of the implant shell (A) with intact capsule (B) and leaked silicone. (b) A breech in both the implant
shell (C) and capsule, demonstrated by loss of continuity of the echogenic capsular line (D).

inner and outer wall of the shell (membrane) and the
fibrous capsule. Inside the normal implant, lines of rever-
beration artefact can commonly be seen in the superficial
part of the implant, particularly when there is a large
amount of overlying tissue, with the rest of the implant
being homogeneously anechoic. In implants with more
complex shell walls, extra echogenic lines can be present
within the implant wall. A double-lumen implant has an
inner lumen usually filled with silicone surrounded by an
adjustable amount of saline in an outer lumen. This gives
the appearance of an implant within an implant. Implant
corners are smooth and well defined. It should also be noted
that implants can be placed within different planes of the
breast, broadly divided into sub-glandular (superficial to
the pectoralis major muscle) and sub-pectoral (deep to
pectoralis major; Fig 1).

Figure 5 (a) Sonogram demonstrating the “sandwich” sign with echogenic leaked silicone (A) between two folds of implant shell (B). (b) The
same phenomenon in cross section demonstrating an “echogenic fold”.
 E. Lake et al. / Clinical Radiology 68 (2013) 851e858 855

Figure 6 (a) Sonogram demonstrating the “snowstorm sign” with echogenic shadowing of leaked silicone obscuring the implant and, (b) the
typical appearance it causes at the corner of the implant.

The anatomy of a rupture
Implant rupture can be intra-capsular or extra-capsular,
the former being a loss of integrity of the silicone shell
alone and the latter being a breach in both the shell and the
surrounding fibrous capsule. An isolated intra-capsular
rupture is more common and is contained by the fibrous
capsule. Extra-capsular ruptures tend to cause more
symptoms as the silicone can extravasate into the local
tissues. Migration to lymph nodes can occur in both types of
rupture and in large gel bleeds, but is more prevalent in
extra-capsular ruptures.15
Sonographic signs of implant rupture
Debris sign
It is thought that this is a change to the sonographic
properties of the silicone due to contact with tissue fluids

Figure 7 Sonogram showing sub-pectoral silicone leakage with Figure 8 Sonogram showing the “bleb sign”, a bleb of hypoechoic
echogenic silicone (A) seen tracking beneath the pectoralis major leaked silicone (A) lying between implant shell (B) and capsule (C),
muscle (B). without posterior shadowing.
856 E. Lake et al. / Clinical Radiology 68 (2013) 851e858

Figure 9 Sonograms demonstrating axillary lymph nodes containing echogenic leaked silicone causing “snowstorm” posterior shadowing.

changing its physical structure, and hence its reflectivity
from anechoic to echogenic. This may be related to shell
rupture or to ageing of the implant with increased perme-
ability of the shell membrane. Venta et al. showed that
heterogeneous aggregates of material within the normally
anechoic interior of the implant were present in nine out of
22 ruptured implants they imaged compared with only
three out of 56 intact implants.12 Sometimes large areas of
contiguous echogenic material can be seen almost filling
the entire implant, which should be regarded as an early
sign of implant rupture (Fig 2).
Stepladder sign
The “stepladder” sign is one of the most well-known
ultrasound signs of intra-capsular implant rupture. It con-
sists of multiple discontinuous linear echos, which repre-
sent the folded margins of a ruptured implant shell. A
number of series have found this to be a significant sign,
with one study reporting the sign as present in 16.7% of
ruptured implants compared to only 3.4% of intact
implants.16,17 The silicone filler has leaked out and the
implant shell has partially collapsed. This is equivalent to
the “linguine” sign seen at MRI (Fig 3).
folds (“the filling”). The “echogenic fold” is the same phe-
nomenon but seen in cross section. This manifestation has
been described at MRI as the “keyhole” or “teardrop” sign as
the cross section of the infolding of the implant shell
resembles these shapes18 (Fig 5).
The “snowstorm” sign and the “echogenic corner”
The “snowstorm” sign is one of the most well-recognized
sonographic signs of implant rupture, which has been
shown to be a sensitive and statistically significant sign of
extra-capsular rupture.17 This phenomenon is thought to be
caused by phase aberration due to the loss of coherence of
the ultrasound beam as it passes through tissue impreg-
nated with silicone, which has taken on water molecules. It
should be noted that this is not a phenomenon that is seen
in large masses of silicone, where the beam remains

Shell membrane breach/capsular breach

The echogenic lines representing the shell wall should be

continuous around the implant. Although the posterior wall
is often hard to see on ultrasound, the anterior wall and side
walls are seen with good detail, and a focal discontinuity of
the echogenic implant shell here represents a directly
visualized breach. When the echogenic line representing
the fibrous capsule is breached this suggests extra-capsular
rupture (Fig 4).

The “sandwich” sign and “echogenic fold”

The sandwich represents two folds of shell wall (“the Figure 10 Multiple signs of implant rupture including an echogenic
bread”) with leaked intra-capsular silicone between the corner (A), implant shell breach (B) and debris within the implant (C).
 E. Lake et al. / Clinical Radiology 68 (2013) 851e858 857

coherent and propagates through the silicone, albeit with
some possible refraction.19 Snowstorm can occur in free
silicone surrounding the implant shell, within the breast
tissue itself or within lymph nodes. Typically, this can
be seen around the margins of the implant as an
echogenic shadow obscuring the clarity of the corner of the
implant (Fig 6).
Sub-pectoral leakage
When silicone has breached the fibrous capsule, it is free
to move around within the breast and further afield.
Echogenic free silicone can sometimes be seen in the sub-
pectoral region. This finding is particularly clear deep to
the more lateral fibres of the pectoralis major muscle (Fig 7).
Intra-capsular bleb sign
The intra-capsular bleb sign is formed when a solid lump
of silicone escapes the shell of the implant and sits between
a fold of the implant and the fibrous capsule wall. If it has
not taken on water molecules, it can appear hypoechoic
similar to silicone within the implant itself (Fig 8).
Silicone node
When silicone escapes into the body tissues, it can be
transported by the lymph system to the lymph nodes. The
most common site for this is the ipsilateral axilla as this
follows the normal lymph drainage pathway of the breast.

Figure 11 (a) Sonogram demonstrating a retained bleb of silicone between the implant shell and capsular wall following implant removal and
replacement. (b) Normal infolding of an implant shell mimicking a collapse. (c) Double-lumen implant with the inner luminal wall (A)
mimicking a collapsed implant shell. (d) Reactive fluid around a recently placed implant.
858 E. Lake et al. / Clinical Radiology 68 (2013) 851e858
However, there are cases of more distant spread, such as the
iliac nodes. Interestingly, silicone has also been known to
enter the ductal system and be expressed at the nipple and
travel transcutaneously to the surface of the skin.20 Silicone
nodes show a typical snowstorm appearance (Fig 9).
Multiple signs
The signs mentioned above can often be seen together;
however, it is important to remember that not every sign is
seen in every patient. Visualizing multiple signs in relation
to an implant should give the sonologist more confidence in
diagnosing rupture (Fig 10).
Pitfalls
Retained silicone
When a ruptured implant is removed and replaced, small
foci of silicone may be left behind in the cavity. As silicone is
inert, it will not dissipate over time and these foci can be
misinterpreted as having come from the new implant. This
problem can be easily avoided with knowledge of the
patient’s implant history and a level of suspicion for this
possibility (Fig 11a).
Normal implant folds
Normal folding of the implant can be misinterpreted as a
sign of rupture. When these folds are seen in cross section,
they are lines termed radial folds and can be differentiated
from the lines seen in the “stepladder sign” by the fact that
they can be traced out to the implant shell (Fig 11b).
Double-lumen implants
The inner lumen of an expandable implant may be
mistaken for a collapsed implant shell (Fig 11c).
Post-implantation fluid
Following implantation, reactive fluid is often seen
around the edges of the implant. This is a normal finding
and should not be confused with silicone (Fig 11d).
Conclusion
Ultrasound is a highly effective tool in the diagnosis of
breast implant rupture. Knowledge of the normal appear-
ances, sonographic signs, and pitfalls presented here com-
bined with a careful methodical approach and a high level
of suspicion is invaluable in correctly identifying rupture of
silicone breast implants.
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