Invasive and Other Procedures Flashcards
Breast implants have been used for over a
century
Today, an estimated _____________ women have breast implants
6 million
What are the 2 types of breast implants? Which one is more popular?
Silicone and saline
Silicone, more natural look/feel
Are single or double lumen implants more popular?
Single
Since the speed of sound is much slower in silicone, what will we seen when imaging?
A step off phenomenon. The tissue deep to the implant will appear further away
Do we see the step off phenomenon with saline implants?
No, the speed of sound in saline and soft tissue is similar
Breast implants typically consist of what type of shell?
elastomer shell or envelope (composed of hard silicone)
The body then forms a fibrous capsule around the implant in attempt to wall it off
Breast implants can be placed in which 2 locations?
Subglandular
Subpectoral
Subglandular implants are placed where:
Between the glandular and pectoral muscle (anterior to the pectoralis major muscle
Acute angle to the inferior margin of the pect major muscle
Subpectoral implants are placed where:
Between the pectoralis major and minor muscles
Obtuse angle to the inferior margin of the pect major muscle
A normal fibrous capsule-elastomer shell complex appears as? What do the lines represent?
a smooth, trilaminar line
Outer- outer aspect of fibrous capsule
Middle- inner aspect of fibrous capsule and the outer wall of the elastomer shell
Inner- inner wall of the elastomer shell
What’s the speed of sound in silicone? Soft tissue?
990m/s
1540m/s
What eliminates the reverberation artifact in an implant?
Single focal zone at the anterior implant surface
What normal appearance may be seen in an implant?
Radial folds, may be confused w rupture
Should a normal implant be compressible?
Yes. A firm, non compressible, rounded or balloon shaped implant is a sign of capsular contracture
What are gel bleeds?
A normal variant. Can’t be seen on sonography, as they are microscopic diffusion of the silicone across an intact membrane. However, if the silicone travels and accumulates within nearby LN’s, it caused them to enlarge and demonstrate the appearance of free silicone.
Do capsular calcifications indicate capsular contracture or rupture?
No
When do we see capsular calcifications? What is thought to cause it?
We see it in older implants. Thought to be caused by chronic inflammation at the site of the implant
Is it normal to see fluid around the implant?
Yes – periprosthetic fluid. Esp w/ polyurethane implants.
Why is it important to know if the patient has a single or double lumen?
As echogenic lines within an implant compartment may be suspicious of implant rupture.
Double lumens will have 5 lines
What are Becker expanders?
An inner chamber that is filled through a valve by a series of small serial injections in order to help expand the tissue in preparation for a permanent implant. The outer silicone compartment may appear echogenic.
What can a Becker expander be mistaken as?
Rupture
What’s the most common complication of breast implants?
Capsular contracture
What is capsular contracture?
Scar tissue forms on the implant and squeezes varying degrees of firmness, discomfort, and implant deformation. May occur right after surgery or years later. May be symmetric, asymmetric, unilateral or bilateral.
Grade 1 (none) capsular contracture:
Augmentated breast feels as soft as the unoperated breast
Grade 2 (minimal) capsular contracture:
The augmented breast is less soft, the implant can be palpated by is not visible
Grade 3 (moderate) capsular contracture:
The augmented breast is firmer; the implant is felt easier and its presence is visible.
Grade 4 (severe) capsular contracture:
The implant is firm and often tender, painful, cool and distorted. Its presence is obvious.
What’s the typical lifespan of an implant before it can rupture?
13yrs
Saline implant rupture:
can be diagnosed clinically, as the implant deflates rapidly. Saline is reabsorbed by the body and the implant may appear as folded in on itself
Silicone implant rupture:
Silent. However, some pt’s may experience changes in size and shape of the breast, pain or tenderness, numbness and a burning or tingling sensation.
Intracapsular rupture:
occurs when there’s a break in the elastomer shell and silicone leaks out, but the silicone is still confined within the fibrous tissue capsule that the body has formed around the implant
What’s the most common type of silicone rupture?
Intracapsular
What signs do we see w intracapsular rupture?
Key hole/noose sign, subscapular sign, and stepladder sign
Keyhole / Noose Sign
Early sign of intracapsular rupture. It is when the apex of a radial fold becomes an area of weakening of the implant shell, silicone may collect within the fold, causing it to expand and produce a ‘keyhole’ or ‘noose’ sign
Subscapular sign:
Silicone may escape through weak areas within the shell and expand the space between the fibrous capsule and the elastomer shell, disrupting the normal trilaminar appearance of the capsule/shell complex.
Stepladder sign aka parallel line sign:
As silicone escapes the implant shell, the shell progressively folds inwards on itself and produces a series of thin, parallel, echogenic lines.
Which sign is the most reliable finding to suggest intracapsular rupture?
Stepladder/parallel line sign
The stepladder sign is analogous to the _______________ on MRI
Linguine
Implants can also contain ______, which may mimic rupture
Impurities
What is it called when there’s a rupture in both the elastomer shell of the implant and the fibrous capsule, and silicone moves freely into the surrounding breast tissue?
Extracapsular rupture
Snowstorm sign:
aka echogenic noise
Hyperechoic, homogenous echoes w a loss of the posterior wall
Can also be identified in axillary LN’s
Silicone masses (granulomas) may be similar to
snowstorm sign
What’s the difference between silicone masses and the snowstorm sign?
Granulomas can appear as the echogenic noise, but also can appear hypo or hyperechoic, and similar to other breast lesions like carcinomas, or anechoic like cysts
A telltale sign of extracapsular rupture?
Snowstorm appearance
The speed of sound in silicone is much ________ than that in soft tissue. Consequently, structures on screen appear _________ than they actually are:
slower; deeper
Why is the anterior margin of a snowstorm sign well defined but the posterior detail is lost in echogenic noise?
Thought to be caused by phase aberration related to the speed of sound being slower in silicone than the surrounding soft tissues
What’s the most common type of silicone breast implant?
Single lumen, gel filled (at approx 80%)
What’s the second most common silicone implant?
Double lumen implant w an inner silicone chamber surrounded by saline
Is mammo or ultrasound better at detecting implant ruptures?
Ultrasound
What makes MRI better than US?
avoids the steep learning curve and operator dependence
What (non contrast) DI modality is the most accurate method of detecting breast implant failure?
MRI
Radial folds can be seen in which imaging modalities?
US and MRI (not mammo)
The linguine sign shows what?
Intracapsular rupture on MRI
MRI scans for breast implants are performed _______ contrast. MRI scans for mass lesions are performed _________ contrast
without; with
Constrast - gadolinium