Women have undergone augmentation mammoplasty for decades, and if implant rupture is suspected, imaging modalities such as magnetic resonance imaging (MRI) and ultrasonography are available. The linguine sign, keyhole sign, and noose sign are all suggestive of rupture. However, earlier-generation implants with alternative filler materials demonstrate rupture signs that differ from those of today’s better-known implant materials. A 60-year-old female patient who had undergone augmentation mammoplasty 20 years ago presented with left breast swelling and pain in the lower-outer quadrant. Ultrasonography and MRI confirmed extracapsular diffuse wall enhancement with suspected, but not apparent, discontinuity in the patient’s left breast implant. Therefore, both implants were removed. It was determined that these were Poly Implant Prothése implants. The left breast implant differed from the contralateral implant in that it contained fluctuating fluid. This could be attributed to an osmotic gradient that caused the implant to swell and weakened the elastomer shell, resulting in micro rupture without a gross tear. Patients who undergo augmentation mammoplasty should have regular follow-up examinations, even if there are no symptoms. Furthermore, clinicians should be aware that some patients who have had breast augmentation mammoplasty may experience atypical symptoms and signs if the implant ruptures.
Since the 1960s, when silicone implants were first used, they have evolved with increased strength, reduced gel bleeding, and improved durability. The so-called third-generation silicone implants were developed with these improved properties. However, the U.S. Food and Drug Administration (FDA) called for the temporary removal of third-generation implants from the market in 1992, citing insufficient data to demonstrate the safety and effectiveness of breast implants. As alternatives, implants made of hydrogel or triglyceride appeared on the market. However, the severe side effects of these newly manufactured implants (e.g., Misti Gold and Novagold) caused them to be withdrawn from the market. The U.S. FDA finally lifted restrictions on silicone implants in 2006. The use of silicone implants was not permitted in Korea from 1992 to July 2007. However, regulation of implantable agents was lax at the time and many patients underwent implantation of the various injectable filler materials or alternative implants mentioned above, resulting in social and medical issues that persist to this day.
Poly Implant Prothése (PIP) is a French breast implant manufacturer. When the use of silicone implants for cosmetic purposes was prohibited in 1992, they began producing saline-filled and hydrogel-filled implants encapsulated in a silicone shell. In 1999, the FDA refused to approve PIP’s saline-filled implants, and in December 2002, the Medical Devices Agency of the United Kingdom’s Department of Health withdrew its hydrogel implants from the market for precautionary reasons. Hydrogel implants were widely used in Korea from 1999 until 2002, when they were outlawed. Later, silicone implants were reapproved by the U.S. FDA and the Korean Ministry of Food and Drug Safety (MFDS) in 2006 and 2007, respectively. However, in 2010 it was discovered that PIP had been using unapproved industrial-grade silicone in their implants since 2001. These implants had a higher rate of rupture that resulted in legal issues for the company and eventual bankruptcy. After the French medical safety agency recalled its implants, PIP was put into liquidation. There have been other reports of PIP implants identified after implant removal that presented with various clinical courses and imaging reports.
Several implant rupture cases have been reported with variable findings. Some implants had a peri-implant fluid collection, while others had gross tears on the surface of the implant. Herein, we present a case of atypical implant rupture and fluid shifting without a significant gross tear of the shell. We also examined studies on PIP implant rupture cases as well as specific radiologic findings in PIP implant rupture.
A 60-year-old female patient who had gone augmentation mammoplasty 20 years ago had been experiencing left breast swelling and pain in the lower-outer quadrant (LOQ) for several months. Ultrasonography of the breasts indicated rupture of both breast implants. The patient was referred to our center, where she underwent a magnetic resonance imaging (MRI) examination as well as breast ultrasonography.
MRI showed diffuse wall enhancement on the extracapsular diffuse wall enhancement and the outer portion of the left implant was suspected to be discontinuous. A 1.2×3.2-cm non-mass enhancement with T2 high signal intensity was discovered 3.7 cm from the nipple in the 5 o’clock direction (
Both implants were removed through inframammary incisions. It was determined that the implants used for this mammoplasty augmentation were manufactured by PIP. Within the silicone shell, a yellowish fluctuating sticky fluid was observed that had not mixed with the remaining hydrogel, and no remarkable tear was found in the shell (
Multiple efforts have been made to develop an implant with a natural shape and feel. Although there is no absolute standard for the ideal breast, certain female breast characteristics, such as a full, sloping upper pole that leads to a fuller, gently curving lower pole, are widely recognized as aesthetically favorable.
Silicone implants were removed from the market in 1992 because of safety concerns [
In one case report, 12 patients presented to an outpatient clinic with swelling, size change, and changes in sensation [
In our case, the patient complained of left breast swelling and pain. She underwent MRI and ultrasonography, both of which revealed abnormalities. MRI depicted diffuse wall enhancement on the left extracapsular space, and there was non-mass enhancement with T2 high signal intensity around the implant at 5 o’clock (
Many social issues concerning breast implants have recently been raised. Because of a critical complication (i.e., breast implant-associated anaplastic large cell lymphoma), Allergan Biocell textured implants were withdrawn from the market. The BellaGel micro-texture implant has been halted following the discovery of the illegal use of unapproved materials. Some patients even complain of a cluster of symptoms such as fatigue, memory loss, and joint pain after receiving breast implants that improves after the implants are removed, a condition known as breast implant illness [
Before the official approval of silicone implants by the Korean MFDS in 2007, many other implants such as hydrogel and triglyceride implants had been used. Even though the hydrogel PIP implant was removed from the Korean market in 2002, there have been reports of PIP hydrogel implants being used during this period. Those patients who had augmentation mammoplasty with PIP hydrogel implants may still have them in their breasts. Several reports describe the rupture of PIP hydrogel implants [
No potential conflict of interest relevant to this article was reported
The patient provided written informed consent for the publication and the use of her images.
Magnetic resonance image of the patient’s breasts. (A) Diffuse wall enhancement is noted on the lateral side of the left breast. (B) Silicone suppression showed that the signal intensity of the inner material was still high, indicating that the implant might be a hydrogel implant.
Ultrasonography of the left lower-outer quadrant. Diffuse heterogeneous parenchymal echotexture was observed.
Explanted left breast implant. (A) There was no remarkable tear in the shell. (B) A yellowish fluctuating sticky fluid was observed within the shell, which was not mixed with the remaining hydrogel.