What is the best imaging modality for a patient with breast implant pain after a fall contusion?

Imaging for Breast Implant Pain After Fall Contusion

Ultrasound (US) should be the initial imaging modality of choice for evaluating breast implant pain following a fall contusion, regardless of the patient's age or implant type. 1

Age-Based Imaging Algorithm

For patients under 30 years:

• First-line: Ultrasound examination 1
• Second-line (if ultrasound findings are equivocal):
  • For silicone implants: MRI without contrast 1, 2
  • For saline implants: No additional imaging typically needed as rupture is usually clinically evident 1

For patients 30-39 years:

• First-line: Ultrasound examination 1
• Second-line (if ultrasound findings are equivocal):
  • For silicone implants: MRI without contrast or diagnostic mammography/DBT 1, 2
  • For saline implants: Diagnostic mammography/DBT may help confirm findings 1

For patients 40 years and older:

• First-line: Ultrasound examination 1
• Second-line (if ultrasound findings are equivocal):
  • For silicone implants: MRI without contrast or diagnostic mammography/DBT 1
  • For saline implants: Diagnostic mammography/DBT 1

Specific Findings to Look For

On Ultrasound:

• For saline implants: Collapsed implant shell (visible when ruptured) 1
• For silicone implants:
  • Intracapsular rupture: "Stepladder sign" (horizontal echogenic lines within implant) 1
  • Extracapsular rupture: "Snowstorm pattern" (silicone outside implant) 2
  • Uneven implant shell (highly specific for rupture) 3

On MRI (for silicone implants):

• Intracapsular rupture: "Linguini sign" or "wavy-line sign" (collapsed shell within gel) 1, 2
• Incomplete intracapsular rupture: "Keyhole," "teardrop," or "inverted-loop" signs 1, 2
• Extracapsular rupture: Silicone outside the fibrous capsule 1, 2

Evidence Strength and Considerations

Ultrasound has been shown to have high diagnostic accuracy for implant integrity evaluation with reported sensitivity of 98.3%, specificity of 89.2%, and overall accuracy of 94.7% 3. While MRI remains the gold standard for detecting intracapsular silicone implant rupture (sensitivity 87%, specificity 89.9%) 1, 2, ultrasound is more readily available, less expensive, and does not have the contraindications that MRI may have.

For trauma cases specifically, ultrasound is particularly valuable as the initial imaging modality because:

1. It can immediately assess for fluid collections around the implant
2. It can evaluate both the implant shell and surrounding tissues
3. It allows real-time assessment during the examination 1, 3

Important Caveats

• Clinical examination alone is unreliable for detecting implant rupture, with sensitivity as low as 42% 4
• Normal implant folds can sometimes be mistaken for rupture on ultrasound 2
• For saline implants, rupture is usually clinically evident as the saline is resorbed by the body over days, causing noticeable breast contour changes 1
• If a patient is uncertain about implant type, ultrasound can determine this by examining the implant margin (silicone implants show a "step-off" appearance not seen in saline implants) 1
• Recent advances in elastography combined with high-resolution ultrasound may further improve diagnostic accuracy 5

By following this imaging algorithm based on patient age and implant type, clinicians can efficiently evaluate breast implant pain after fall contusion while minimizing unnecessary radiation exposure and costs.