I am 45 years old and had Silicone Gel implants for 20 years. One side became firm 6 years ago. My family physician ordered an ultrasound and it suggests rupture of the implant. Should I have further x-ray studies done to make sure?
This is a common issue confronting plastic surgeons. The answer is rather complex and should involve a consultation with your plastic surgeon. Some recent research papers give some guidelines and the general thinking follows this line of reasoning.
This patient who has probable intracapsular (without spread into the breast itself) rupture of one of her 20-year-old silicone gel implants requires surgery to remove the ruptured implant and periprosthetic capsule. Test characteristics (sensitivity and specificity) and implant rupture prevalence have been used to calculate the probability of rupture for various patient scenarios. In asymptomatic patients, the pretest rupture prevalence is estimated at 6.5%. Ultrasonography shows no rupture, the probability of rupture drops to 2.2%. No further work-up is necessary. If ultrasonography suggests rupture, the relatively low probability (37.8%) of true rupture requires a confirmatory test using MRI.
In symptomatic patients (i.e., patients who have breast asymmetry or capsular contracture), the high prevalence of rupture markedly raises the probability of rupture after positive findings on ultrasonography. In symptomatic patients whose implants are no more than ten years old, the prevalence of rupture is estimated to be 31%. Positive ultrasonography increases the probability of true rupture to 79.7%, and this probability is increased to 97.5% if a follow-up MRI shows rupture. In this woman and other symptomatic patients whose implants are more than ten years old, the high probability of true rupture (94%) after positive findings on ultrasonography obviates the need for any further diagnostic testing such as MRI.
Observation is inadequate because implants that are known or suspected to be ruptured should be removed. Mammography is recommended for screening of benign and malignant diseases. However, evaluation of implant status by routine mammography is limited, particularly in cases of intracapsular rupture. Not all of the implant and surrounding breast tissue can be visualized, and patients with severe capsular contracture and painful breasts may not be able to undergo the compressive technique required to execute the study. Only when the silicone has migrated away from the fibrous capsule (extracapsular rupture) can mammography offer accurate diagnosis.
Beckman WH et al. Plast Reconstr Surg. 1998;102:1281-1289
Chung KC et al. Plast Reconstr Surg. 1998;102:1281-1289