There are different possibilities for the examination of breast implants. First and foremost is the clinical examination, which today is increasingly being pushed into the background by apperative methods and is highly dependent on the experience of the examiner. The radiological possibilities range from MRI and ultrasound to classical X-rays in mammography and CT. Nevertheless, breast implants do not require routine examination annually. If there is, due to symptoms or the physical examination, clinical concern of the implants integrity, ultrasound should be the first-line diagnostic modality.
If the ultrasound findings are questionable, or if there is persisting clinical concern, then MRI is indicated.
MRI is widely accepted as the imaging method of choice to evaluate the implants integrity with a sensitivity and specificity of greater than 90% in evaluating implant rupture . Current recommendations by the FDA are that women with silicone breast implants, should undergo MRI Scans 3 years after augmentation and every second year afterwards . In a recent a study be the European Institute of Oncology it was concluded, that MRI should be the modality of choice to diagnose implant rupture in asymptomatic women due to the superior accuracy compared to ultrasound. However, it is recommended to do routine screenings with ultrasound imaging. If irregularities using ultrasound are detected, MRI imaging should follow to verify (29).
Signs of implant rupture: Quelle 24
Degree of Collapse
Description of Rupture
Keyhole sign/ noose sign
Silicon gel is contained in a radial fold
Subcapsular line sign
minimal collapsed rupture
extruded silicon gel separates the elastomer shell form the fibrous capsule
partial-full collapsed rupture
silicon gel entirely in the intracapsular space
Mammographie is the most used and inexpensive modality. It has only a low sensitivity due to (11-69%) high radiopaque of silicon [13, 17-19]. Breast Implants represent themselves in mammography as uniformly dense. A further evaluation of the implant, can be made only limited . Therefore implant ruptures can be overseen.
The benefits of Mamography are the following: a detection of extra capsular ruptures is possible ().
Possible signs of implant rupture are (non-specific):
Irregular shape of the implant
Lobular and/or spherical density
Herniation (protrusion of the implant through opening in the fibrous capsule)
Mammography remains the imaging method to detect breast cancer and not the integrity of breast implants. However the type of implant can be determined and it is possible to distinguish between saline an d silicon single lumen implants. Further free silicon in cases of extracapsular implant rupture can be detected. For the verification of a intracapsular rupture are additional imaging methods as MRI or ultrasound necessary.
Ultrsaound should be a standard method in the evaluation of both, asympomatic and symptomatic breast implants.
Sonongraphy is a ubiquitous available, expeditiously, easy for the patient to undergo with nearly no discomfort and cheap imaging method. In opposite to MRI and Mammography it can detect extra and intracapsular ruptures:
Extracapsular rupture: snowstorm sign
Intracapsular ruptures: stepladder sign 
high operator dependent. Therefore the examination should be performed by a specially trained breast sonographer
Technical ultrasound considerations
The sonography of breast implants is highly operator dependent and should be pursued by a special trained breast sonographer. Further more, as shown in our studies, a high frequency probe 12,5-33 MHz (linear) should be used in the evaluation of implants. Only the high frequency probes allow a precise imaging of the capsule-elastomer-shell complex. The downside to high frequency sonography is a limited examination depth. In women with larger breast it should be considered to use a lower frequency (9-16 MHz) to gain further depth. Light compression on the breast should be applied during scanning.
Implant appearance in ultrasound
Intact implants are anechoic . If a fibrous capsule starts to built around the implant, a capsular-shell-complex can be shown using ultrasound technology. This fibrouse-elastome-shell complex appears in sonography mostly as a trilaminar line [19, 21]. The outer surface of the capsule is shown by the outer line in the ultrasound image. The middle line corresponds to the inner surface of the capsule and the outer surface of the elastomer shell. The inner line represents the inner surface of the elastomer shell [18, 21].One should be aware, that orientation marks on the implants can lead to interruption of the trilaminar lines. This should not be mistaken as a implant rupture.Abnormalities as protrusion, herniation, bulging and contour interruption of the elastomer shell occur in areas where the fibrous capsule is thinned and could indicate a a problem with the implant integrityreverberation echoes in the near field must be distinguished from the implants echogenicity. Light compression while sonography can minimize these reverberation artifacts. Further it is possible to detect radial folds. These folds are dynamic and not fixed in position and size.
Extracapsular rupture in sonography:
Snow strom appearance = extravastaed silicon
Homogeneous hyperechoic nodule
Extracasular silicon granulomas (isoechoic nodule)
Double lumen implant rupture:may simulate single lumen implant
Silicon in lymph nodes (may be associated with extracapsular implant rupture)
Hyperechoic lymph nodes (beginning in the hilum and progressing to the cortex) = snowstorm shadowing
Intracapsular rupture in sonography
Steppladder sign= multiple fold of the collapsed implant shell floating with extravasated silicon, occures in large ruptures with nearly or complete collaps
Double lumen implant rupture: mixing of saline and silicon gel components: mottling of echogenicity