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Imaging of Breast Implant–associ-
ated Complications and Pathologic
Conditions1
Sean D. Raj, MD
Evguenia J. Karimova, MD
Michael D. C. Fishman, MD
Valerie Fein-Zachary, MD
Jordana Phillips, MD
Vandana Dialani, MD
Priscilla J. Slanetz, MD, MPH
RadioGraphics 2017; 37:1603–1604
https://doi.org/10.1148/rg.2017170025
Content Code:
1
From the Department of Radiology, Beth Israel
Deaconess Medical Center, Harvard Medi-
cal School, 330 Brookline Ave, Shapiro 408,
Boston, MA 02215. Presented as an education
exhibit at the 2016 RSNA Annual Meeting.
Received February 23, 2017; revision requested
April 24 and received June 6; accepted June 9.
All authors have disclosed no relevant relation-
ships. Address correspondence to S.D.R.
(e-mail: sean.raj@gmail.com).
©
RSNA, 2017
1603
RADIOGRAPHICS FUNDAMENTALS |
The full digital presentation is available online.
Breast augmentation has been performed for more than a century
and in the past few decades has gained in popularity for cosmesis or
reconstruction after mastectomy for breast cancer. With the exten-
sive advancements in surgical techniques and prostheses, familiarity
with the multimodality imaging appearances of the different types of
augmentation, including implants and direct injection of fat, silicone,
BREAST IMAGING
or other materials, as reviewed in the accompanying online presenta-
tion, helps the radiologist recognize and diagnose associated com-
mon and uncommon complications and pathologic conditions.
Augmentation can be broadly characterized by material compo-
sition and type. Although there are numerous chemicals, oils, and
materials used worldwide for cosmetic purposes, the vast majority
of augmentation materials are composed of silicone, saline, poly-
acrylamide gel, or autologous fat. These materials are either surgi-
cally placed as packaged single- or double-lumen implants into the
retropectoral or subglandular tissues or directly injected into the
breast tissues. First-line imaging evaluation is mammography and
is performed as part of routine mammographic screening to deter-
mine implant location, composition, and gross integrity, as well as to
evaluate other types of injected material. The U.S. Food and Drug
Administration recommends evaluating implant integrity with mag-
netic resonance (MR) imaging 3 years after placement and every 2
years thereafter to depict silent ruptures.
Ultrasonography (US) and MR imaging are more routinely used
when evaluating an implant complication. Common complications
associated with breast augmentation are categorized as early or late
changes. Earlier changes include peri-implant fluid collection or hema-
toma and infection. Later changes include capsular contraction, foreign
body reactions, intracapsular or extracapsular rupture, reactive lymph-
adenopathy secondary to free silicone from direct injection or extracap-
sular rupture, and fat necrosis. Although mammography and US may
TEACHING POINTS
■■ Although MR imaging depicts abnormalities of the augmented breast the most effec-
tively, mammography remains the first-line imaging modality to evaluate augmented
breasts.
■■ Common complications of breast augmentation are divided into early (peri-implant fluid
collection or hematoma and infection) and late (capsular contraction, foreign body reac-
tions, intracapsular or extracapsular rupture, reactive lymphadenopathy secondary to free
silicone from direct injection or extracapsular rupture, and fat necrosis) changes.
■■ Uncommon complications of breast augmentation include retained foreign body (gos-
sypiboma), pericapsular lymphoma, fibromatosis, and sarcoma.
1604  September-October 2017 radiographics.rsna.org

Figure 1.  Intracapsular rupture in a 41-year-old

woman with silicone implants who underwent MR
imaging to evaluate for rupture. Axial T2-weighted
(Ax T2) MR image shows evidence of bilateral in-
tracapsular rupture with collapsed implants, in-
cluding an intact fibrous capsule (yellow arrows);
the linguine sign (red arrow) as demonstrated by
the wavy lines made by the collapsed implant shell
contained within the capsule; and the subcapsular
line (purple arrows), noose (orange arrows), and
keyhole (pink arrow) signs, which all show silicone
on both sides of the envelope.

Figure 2.  Implant-associated fibromatosis in a 49-year-old woman with a history of

risk-reducing bilateral mastectomy for lobular carcinoma in situ and silicone implant
reconstruction with a palpable mass in the right inframammary region. (a) US image
demonstrates a heterogeneously hypoechoic mass (yellow arrow) abutting the implant
(red arrow). (b) Sagittal postcontrast T1-weighted subtraction (Sag T1 C+ Sub) MR
image corresponding to the reported palpable and sonographic abnormality shows
an enhancing mass (green arrow) adjacent to but separate from the silicone implant.
US-guided core biopsy results confirmed a spindle cell lesion. Surgical excision results
revealed fibromatosis.

depict many of these findings, MR imaging remains
the most sensitive and specific modality to depict
silicone implant rupture (Fig 1). Most women opt
for implant removal followed at times by replace-
ment, even though a ruptured breast implant does
not pose a health risk.
Unusual complications associated with breast
augmentation include retained foreign body (gos-
sypiboma), pericapsular lymphoma, fibromatosis
(Fig 2), and sarcoma. Multimodality imaging is
typically used to evaluate these unusual compli-
cations with a combination of mammography,
US, and MR imaging. When imaging findings are
indeterminate, management may entail percuta-
neous image-guided biopsy or surgery, depending
on the suspected diagnosis. In the setting of ma-
lignancy, implant removal may become necessary
to expedite appropriate treatment. A meta-analy-
sis of 3 decades of literature on breast cancer and
augmentation revealed no increased risk for de-
veloping breast cancer, no proven delay in breast
cancer detection, and no difference in survival
length or frequency of breast cancer recurrence
compared with women with no augmentation.
In summary, an understanding of the types
of augmentation and possible complications is
critical to providing appropriate care to patients
and ensuring proper management. Imaging with
mammography, US, or MR imaging can be help-
ful in characterizing the augmented breast and
guiding the appropriate intervention.
Suggested Readings
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Venkataraman S, Hines N, Slanetz PJ. Challenges in mammogra-
phy: part 2, multimodality review of breast augmentation—
imaging findings and complications. AJR Am J Roentgenol
2011;197(6):W1031–W1045.
Yang N, Muradali D. The augmented breast: a pictorial re-
view of the abnormal and unusual. AJR Am J Roentgenol
2011;196(4):W451–W460.