Imaging and surveillance in patients with breast implants

Introduction

Following initial interest in ultrasound and breast implant evaluation in the 1980s, mainly in the UK, there has been very little research or clinical experience reported in our specialty. The final slide of the first national presentation of high resolution ultrasound (HRUS) in 2008 stated: “High Resolution Ultrasound will be in every plastic surgeons office at some point in the future …” However, integration of HRUS into plastic surgery has been a very slow process. In 2021, there appears to be a renewed interest with more ultrasound companies and surgeons finding new ways to utilize ultrasound. One of the core reasons is the convergence of technologies. As breast implant technology continues to improve with stronger more consistent shells, higher fill volumes, and more cohesive silicone fillers, HRUS is improving with significant advances in the ultrasound technology. This convergence is creating significant and high degrees of sensitivity and specificity with this technology, exceeding, in most cases, prior magnetic resonance imaging (MRI) data ( Tables 13.1 & 13.2 ). Gone are the days of thin undulating shells, markedly underfilled implants, double lumen implants and high rates of capsular contracture, that can decrease the accuracy of ultrasound, creating false positives. These older implants have many reasons for replacement other than shell failure, including their age, but in evaluating current state-of-the-art breast implants, it is becoming more difficult to make a wrong diagnosis verses a correct one.

Everyone needs improved implant screening including the Food and Drug Administration (FDA), implant manufacturers, and plastic surgeons, but particularly our patients. In October 2019, the FDA removed the prior MRI requirement for breast implant follow-up at 3, 5 and 7 years following implantation and recommended HRUS as an alternative for asymptomatic screening of implants. Current recommendations are for HRUS for screening asymptomatic patients with a diagnostic MRI for any suspected rupture. As clinical data and experience continues to grow, HRUS may well overtake MRI as the best and most accurate “gold-standard” method to diagnose shell abnormalities along with fluid collections.

There have been some recent excellent articles describing the basics of HRUS and background directed to plastic surgeons and plastic surgery applications. HRU evaluation requires a system. The system includes an ultrasound hardware platform, a high resolution transducer 12 MHz or higher, a software program and a display. There are several systems on the market today that create consistent high quality images to screen and diagnose shell abnormalities accurately ( Fig. 13.1 ). Along with shell failure, HRUS can determine whether an implant shell is textured or smooth ( Fig. 13.2 ), evaluate capsular thickness or visualize acellular dermal matrices (ADM) ( Fig. 13.3 ) and whether any fluid is surrounding the device ( Fig. 13.4 ).

One of the main goals for the future is to integrate HRUS more effectively and efficiently into our practices. Dedicated systems for both the clinic and the operating room are very useful.

Particularly when surgeons are just starting out with ultrasound, it is helpful to image the patient directly on the table just prior to making an incision to confirm exactly what is being visualized on ultrasound and how it appears clinically. Operating room devices may also be utilized for ultrasound-guided transabdominal placement (TAP) of Marcaine or Exparel ( Fig. 13.5 ), and facilitation of fat transfer. Performing HRUS on every revision breast implant patient immediately prior to surgery, which allows for direct feedback on what is visualized on ultrasound, improves individual accuracy and allows for maximum surgeon education. In the clinic it is easy to integrate HRUS into a surgeon’s follow-up examination as described ( Algorithm 13.1 ). In addition, whoever diagnoses the ruptured implant performs the revision procedure and after two or three procedures the surgeon has paid for the technology. In aesthetics, surgeons typically are not charging for the procedure but a set fee, say, “$2000” may be placed on the surgery fee quotation and then subtracted out showing the HRUS follow-up has significant value. In insurance based reconstruction, HRUS-guided seroma drainage or implant follow-up may be coded and billed.

Algorithm 13.1

Algorithm for high resolution ultrasound breast revision.

Integrating HRUS into your plastic surgery practice

Plastic surgeons are only just realizing the potential benefits of in-office HRUS. Countless busy medical and surgical practices that require fast and accurate evaluation of soft tissues, joints, vessels, nerves, surgical sites, indwelling lines and drains, as well as implanted devices, are incorporating HRUS into their practices, often eliminating the need for referrals to a radiologist as they learn to image and interpret what they see. As surgeons, we have the opportunity to rapidly advance our ultrasound skills by routinely performing ultrasounds on as many implant patients as possible, documenting the image, and comparing with intra-operative findings at the time of revision. All breast implants will eventually fail and it is essential that surgeons who perform breast implant procedures have an accurate and reliable means to image their patients as their implants age. HRUS is a cost-effective, dependable method for the evaluation of patients in the office setting.