Breast Asymmetry

This Image of the Week is brought to you by Erika Chowa at Midtown. Her patient presented complaining of new breast asymmetry. The patient had a history of saline breast implants, and had noticed new significant asymmetry that day. The patient had no complaints of pain and no evidence of infection on exam. Dr. Chowa successfully used bedside ultrasound to identify the problem:

In this video, you can clearly see the abnormal contour and irregularity of the fluid-filled saline implant. An intact implant should have a hyperechoic continuous border around a dome-shaped anechoic fluid-filled interior. The irregular borders and abnormal shape seen on this ultrasound are highly suggestive of implant rupture. If a silicone implant has ruptured, there is often leakage of silicone into the surrounding tissue. This has a “snowstorm” appearance on ultrasound, as shown below.

Juanpere S, Perez E, Huc O, Motos N, Pont J, Pedraza S. Imaging of breast implants—a pictorial review. Insights into Imaging. 2011;2(6):653-670. doi:10.1007/s13244-011-0122-3

Implant rupture is not an uncommon complication of breast augmentation - ~10% of saline implants and older-generation silicone implants will rupture, and the rupture can happen at any time during the lifespan of he implant. Newer-generation silicone implants have a lower rate of rupture, although the exact rate is unknown. Rupture of a saline implant is generally quickly noticed by the patient, as it leads to deflation of the implant and significant contour deformity. Silicone implant rupture can be more subtle, as the expelled silicone generally remains within the breast capsule and does not cause a noticeable contour change. Current FDA recommendations include a screening MRI every 3 years after breast augmentation to assess for implant rupture and rotation.

Breast augmentation remains the most common cosmetic surgery in the United States, although lifts (breast and buttocks being the most common) are catching up. In 2015, there were >275,000 new breast augmentations performed in the US. There are millions of people in the United States with augmented breasts, and chances are one will come in to your emergency department with a complication. Reach for your handy ultrasound to diagnose some of the more common issues seen with implants!

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Claire Abramoff MD
Ultrasound Fellow 
Department of Emergency Medicine 
Emory University Hospital