0:00

So a 56 year old female with bilateral breast

0:03

implant prevents for a screening mammogram and Survey

0:06

breast ultrasound.

0:08

So this is her CC and mlo

0:11

views.

0:13

I'm just going to do a minute to look at those to kind of

0:16

get your bearings.

0:17

And then these are the implant displays views which we

0:20

typically get you can see that there is this

0:23

dense, Mass.

0:27

in the right inner breast

0:31

So based on this appearance what type of implants are

0:34

these

0:37

We've got retropectoral silicone retropectoral Saline.

0:43

Retroglandular silicone and

0:46

retrogrillino. No, no, I'm

0:49

Sorry, actually, I don't think anyone's here watching it. So, what's

0:52

the best answer?

0:55

Good wait, so I actually blocked

0:58

myself. So these are retro pectoral silicone good.

1:01

So you see the pec muscle coming around the implant, you

1:04

know, it's silicone because it's high density and you

1:07

can't really see through it and you don't see that typical nozzle,

1:10

which you'll see with a saline implant and I'll show you

1:13

another case of that.

1:15

Um, so what's the best Imaging modality to

1:18

assess for rupture of these?

1:22

of these implants

1:26

I'm going to open this up. Is it MRI mammogram ultrasound

1:29

or none of the above?

1:35

Good. So MRI is the best mammogram. You

1:38

really can't tell in this case. You can kind of

1:41

get the sense that there's some something going on whoopsies. Sorry and

1:44

but you don't exactly know for

1:47

sure. You can go to Ultrasound ultrasound

1:50

will be helpful. But also you're really

1:53

going to want to do an MRI.

1:55

So this is our patient, you know, we did a

1:58

survey ultrasound. This is of her right breast.

2:01

And oh my God, sorry.

2:03

I don't know.

2:04

What just happened?

2:07

So based on this appearance findings are concerning

2:10

for a wish

2:12

intercapsular silicone rupture extra capsular

2:15

silicone rupture extra capsular saline

2:18

rupture, or is it a and b

2:25

little bit of a trick question here

2:28

So yeah, the answer is D and most people

2:31

got that so the if you're gonna have

2:34

extra cap, so if you're gonna have extra capsular rupture,

2:37

you have to have enter capsular rupture. So that will make it a little

2:40

bit easier for you. So if you see the extra capsular,

2:43

you know, it's in your capsular and that's why it's a and b and not

2:46

just B, you know what I wanted to and what

2:49

is the name of this ultrasound appearance?

2:53

Is this the linguine sign the new new sign

2:56

the keyhole sign or is this a snowstorm appearance?

3:02

Okay good. So this is a snowstorm appearance

3:05

and we're going to go through all of the appearances of the

3:08

different types, but I'm glad that some people are don't know

3:11

everything and they're here to learn. So this

3:14

is the snowstorm.

3:16

So this is

3:19

an MRI on the same patient and

3:24

let's open the the poll again.

3:28

So based on this appearance

3:32

that you know the real problems on the right as we've

3:35

seen and we kind of know what's going on. So if you've gotten

3:38

them right to this point, you probably can get this right too.

3:45

Good. So everyone knows now so you see extra capsular

3:48

silicone rupture over here. That's at

3:51

mass that we were seeing you see this. We're going

3:54

to talk all about that. But those are the linguine signs of

3:58

intercapular rupture.

4:01

So referring clinician is concerned about saline implant

4:04

rupture. What study should he order?

4:09

Let's open up the poll here saline implant

4:12

rupture.

4:15

Good, none of the above. So no one fell for it. Yeah, it's you

4:18

don't need an exam to tell you that you have implant of saline

4:21

implant rupture. It deflates like a balloon the patient will tell you

4:24

that she had it. Okay. What is the MRI

4:27

finding on this axial stir image on a different patient?

4:34

Okay, let's close it.

4:37

Yeah, so these are normal radial folds and

4:40

what you know, I think that people often get confused between this

4:43

and intercaps or rupture where you have some silicone in

4:46

you make that makes a

4:49

little Loop like a neat Keyhole or new sign. These are

4:52

actually normal radial folds. So it's normal

4:55

see that but you're looking for that silicone in between the folds.

4:59

Okay.

5:00

What is the finding and significance on

5:03

the axial stir image? So what

5:06

are we seeing here?

5:09

So is a sling weini sign that means intra capsular

5:12

linguine centimines extra capsular snowstorm that means

5:15

intercaps or a snowstorm limited extra.

5:22

Good, so you're getting the hang of it. This is in cleaning linguine

5:25

sign of intercapsular rupture. So it looks like

5:28

a big ball of spaghetti and then plan that's not normal.

5:31

Okay, so to review our case, you

5:34

know this like I said, this is a these are retro pectoral silicone

5:37

implants. You can tell that because they're really high density and

5:40

you don't see the nozzle the peck goes

5:43

in front of it. So if you tree, I always can I can only

5:46

tell on the ml when I see the pet kind of going around the implant here.

5:49

You see a dense Mass. Medially you're

5:52

starting to be suspicious for extra Caps or rupture. But

5:55

really you can't diagnose this on a mammogram. You could be suspicious and

5:58

recommends an MRI, you know, ultrasound is

6:01

definitely helpful. So I'm

6:04

just gonna go through these this is a snowstorm appearance of

6:07

extra capsular silicone. If you have extra

6:10

capsular silicone, you know, you have intercapsular silicone rupture

6:13

too. So you have to have one for

6:16

the other

6:17

So this is like I said, this is the extra capsular

6:20

silicone. You're seeing this is the folded up

6:23

implant amongst itself. This is intercaps are rupture saline

6:26

implant rupture is a clinical exam

6:29

finding and the saline.

6:32

I've seen mri's order for this and then it's totally not

6:35

indicated. This is what it will look like you could tell that this is

6:38

a saline implant because you could see the nozzle you

6:41

can see through it. It's a little bit less dense than the silicone implant

6:44

and this is actually a

6:47

pre pectoral so or a retro glandular that those are

6:50

another term so you can see the peck here kind of goes behind it.

6:53

So in the other case at one in front of it, so this

6:56

is a good case for that.

6:59

These are just normal radial folds. Like I said, you don't see the silicone

7:02

within the folds. This is

7:05

a linguine side. I'm intra capsular rupture and just

7:08

you know, when we talk about a capsule there's an outside fibrous capsule

7:11

and then there's an implant inside of

7:14

it and once it gets outside of the fibrous Capsule,

7:17

that's when it's considered extra capsular. So extra

7:20

Caps or means beyond that fibrous capsule.

7:24

And just to show you three examples and

7:27

next to each other because I think this is helpful. So these are

7:30

normal radial folds in the middle. But as you

7:33

can see and when there's intercapsular rupture,

7:36

you'll see this silicone within the folds. This

7:39

is called a keyhole or new sign looks

7:42

just like that versus and this is

7:45

the linguine sign. This is when it's really bad.

7:48

So on ultrasound you might see this step ladder appearance of

7:51

intercapsular silicone rupture and

7:54

on MRI, you

7:57

might see in this case. You can see silicone extending

8:00

beyond the capsule of the implant. This is extra cups

8:03

or an intercapular rupture.

8:05

All right, so just to reiterate I

8:08

think this is a good.

8:10

Summary slide so, you

8:13

know intercaps are rupture. You'll see the keyhole or news

8:16

and weenie sign an ultrasound. You may see a step ladder sign

8:19

for extra capsular. You may see silicone outside the

8:22

implant may feel lymph nodes like we did it can

8:25

have a snowstorm appearance on ultrasound and you

8:28

must have enter capsular ruptured has extra capsular rupture.