S p e c i a l A r t i c l e s • R ev i ew Yahyavi-Firouz-Abadi et al. Imaging of Cosmetic Plastic Implants
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Special Articles Review
Imaging of Cosmetic Plastic Procedures and Implants in the Body and Their Potential Complications Noushin Yahyavi-Firouz-Abadi1,2 Christine O. Menias 3 Sanjeev Bhalla1 Cary Siegel1 Gabriela Gayer4 Douglas S. Katz 5 Yahyavi-Firouz-Abadi N, Menias CO, Bhalla S, Siegel C, Gayer G, Katz DS
OBJECTIVE. Cosmetic plastic surgery procedures, as well as implants, are increasingly being performed. These implants are often encountered on routine imaging examinations, and radiologists are often asked to evaluate for complications or evidence of failure. Pectoral augmentation, gluteal augmentation, body lift and abdominoplasty, and penile and testicular prostheses are reviewed in this article. CONCLUSION. The typical appearance of common cosmetic implants and cosmetic techniques used in the human body is presented, along with the imaging spectrum of their potential complications.
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Keywords: abdominoplasty, augmentation, body lift, gluteal, pectoral, penile, testicular DOI:10.2214/AJR.14.13516 Received July 19, 2014; accepted after revision September 2, 2014. Based on a presentation at the Radiological Society of North America 2013 annual meeting, Chicago, Il. 1
Mallinckrodt Institute of Radiology, Washington University School of Medicine, St. Louis, MO.
2 Present address: The Russell H. Morgan Department of Radiology and Radiologic Science, The Johns Hopkins Medical Institute, Baltimore, MD. 3 Department of Radiology, Mayo Clinic, 13400 E Shea Blvd, Scottsdale, AZ 85259. Address correspondence to C. O. Menias ([email protected]). 4 Department of Radiology, Stanford University Medical Center, Stanford, CA. 5 Department of Radiology, Winthrop-University Hospital, Mineola, NY.
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wide variety of cosmetic plastic surgery techniques and implants have been developed for improving the appearance of or restoring function to the human body. Recently, additional materials and techniques have been developed for such procedures. Radiologists are involved in the preoperative assessment, planning, and evaluation of postoperative failure and other complications of such cosmetic surgical implants and techniques. Commonly, postsurgical changes and implants represent incidental findings on routine imaging examinations. Radiologists need to be familiar with the spectrum of the normal postoperative appearance of such implants and procedures on different imaging modalities, so as not to mistake them for pathology, particularly neoplasm or infection. In addition, radiologists are often asked to perform and interpret a dedicated imaging examination to evaluate for implant failure or complications. Imaging of female breast augmentation and implants and their complications has been extensively discussed in the literature. However, to our knowledge, imaging features and complications of male chest augmentation, cosmetic body lift techniques, buttock augmentation, and penile and testicular prostheses have not been well studied. After reading this article, radiologists will be more familiar with the expected imaging appearances of implants and cosmetic techniques in the body and the spectrum of imaging fea-
tures of implant complications or failure, with an emphasis on CT and MRI findings. Male Chest Enhancement (Pectoral Augmentation) Pectoral Implant Chest augmentation or enhancement is increasingly performed in men [1]. Most patients are those who are unable or unwilling to build their pectoral muscles with exercise [1]. Less commonly, it is performed in patients with congenital or acquired deformities of the chest wall. Examples of the latter include unilateral congenital absence of the pectoral muscle (Poland syndrome), pectoral denervation due to brachial plexus injury, muscle injury related to sports, pectus excavatum, and postsurgical chest wall deformities [1, 2]. Implants are typically available through manufacturers and are occasionally custom made for a specific patient [1, 2]. Buttock implants have also been used for pectoral augmentation, although they often do not fill the cranial portion of the pectoral muscle [3]. Implants may be placed in a transverse or oblique position depending on the underlying deformity or defect. Pectoral implants are made of silicone rubber, which is easily customizable and has a soft, pliable consistency [1, 2]. Silicone rubber has a variable CT appearance, typically denser than soft tissue but less dense than bone; on MRI, silicone rubber is hypointense on both T1- and T2-weighted images [4] (Fig. 1A).
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Yahyavi-Firouz-Abadi et al. Presurgical planning for customized implants can be performed using either an alginate impression of the chest wall or a 3D reconstruction from a chest CT [2]. CT reconstruction is somewhat more expensive but highly accurate [2]. Rapid prototyping can be done to build a model directly from computer data [2]. This is especially useful in patients with deformities such as pectus excavatum [2, 5] (Fig. 1B). Complications of pectoral augmentation include seroma, hematoma, malposition, extrusion or displacement of the implant, infection, capsular retraction, visibility of the edges of the implant, and over- or undercorrection. Capsular retraction happens as a result of foreign-body reaction and results in deformity and hardening; these are detected clinically and not typically seen on imaging. Some implants are reported to be associated with less implant displacement, including those with a textured surface, surgical stitching, or incorporated holes for ingrowth [2]. CT features that suggest infection include fat stranding, abnormal fluid collections, and hypoenhancement of the pectoral muscle (Fig. 1C). Chest Wall Augmentation Using Free Silicone Injection Free silicone injection was commonly used in the past for breast augmentation in women, but it was banned by the U.S. Food and Drug Administration (FDA) in 1992 because of safety concerns and ineffectiveness [6]. Nevertheless, imaging features of this type of breast augmentation may still be encountered in older patients and immigrants. Rarely, this type of augmentation may be seen in patients who have undergone illegal cosmetic surgery procedures in the United States by unlicensed practitioners. Free silicone injection in men is encountered much less commonly than in women. Complications of free silicone injection include silicone granulomas, fibrosis, and lymphadenopathy [6, 7]. On mammography, multiple dense nodular masses are usually seen. On CT, silicone granulomas appear as soft-tissue nodules with associated fat infiltration (Fig. 2). On MRI, these nodules are hypointense on T1-weighted images, hyperintense on T2-weighted images, and hyperintense on silicone-sensitive sequences [6, 7]. Autogenous fat transfer to the chest wall after liposuction (lipofilling) is also used for pectoral augmentation. It has an imaging appearance similar to breast fat augmentation in women.
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Gluteal Augmentation Gluteal augmentation was introduced in 1965 with the insertion of breast prostheses in the buttocks and is now one of the fastest-growing fields in plastic surgery [8]. According to statistics from the American Society of Aesthetic Plastic Surgery [9], 11,527 patients underwent buttock augmentation procedures in 2013, as compared with 614 in 2002. Gluteal augmentation can be performed using different techniques, such as solid silicone implant placement, autogenous fat augmentation, and filler injection. Gluteal Implant Placement Gluteal implant placement yields the best long-term aesthetic results and is increasingly being performed in the United States [10]. Solid silicone elastomer implants are the sole implants approved by the FDA for buttock augmentation. Most of the literature about gluteal implant placement is from South and Central America, where the use of cohesive silicone gel is preferred over solid silicone elastomer [10, 11]. Solid silicone elastomer has the ability to increase gluteal tone in patients with ptosis, congenital or acquired gluteal deformities, and asymmetry [8]. Different surgical techniques have been described for implant placement, including the use of subcutaneous, subfascial, intramuscular, and submuscular pockets [12] (Fig. 3). Surgical complications including seroma, dehiscence, infection, implant visibility, and implant displacement are reported more frequently with superficial implant placement. Submuscular (between the gluteus maximus and medius) implant placement has the risk of damage to the sciatic nerve and is rarely performed [12] (Fig. 3). Because of submuscular anatomic limitations, only small implants can be placed, which cannot extend beyond the lower edge of the pyramidal muscle, resulting in a “double-buttock” appearance. In the intramuscular method, the gluteal muscle is bisected, and the implant is placed in between the layers. Intramuscular placement using the “XYZ” method has recently been described and is reported to have the lowest complication rate [13]. In this method, the surgeon splits the gluteus maximus muscle into two equal halves with anatomic reference points to determine the ideal implant plane and guide symmetric muscle detachment at an adequate depth [13]. A systematic review of the literature reports the complication rates for different locations as follows: 55% for subfascial, 18% for intra-
muscular, and 18% for submuscular versus 13% for intramuscular XYZ methods [12]. Complications include seroma (as well as late seroma), hematoma, dehiscence, infection, capsular contracture, pain, implant visibility, and implant rupture. The appearance of gluteal silicone rubber implants on CT and MRI is the same as previously discussed for pectoral implants. As with other implants, both hematomas and abscesses may present with fluid collections on imaging (Fig. 4). When fat stranding is seen, infection should be suspected. For cosmetic implants (buttock, pectoral, and mammary), removal is the mainstay of treatment [14]. However, management depends on clinical findings and severity of infection. As shown in Figure 1C, in a patient with an infected pectoral implant—signs of which included abscess, myositis, fever, and leukocytosis—the implant was removed. By contrast, minor infection, such as superimposed infection in a postoperative seroma, could potentially be managed initially with percutaneous drainage (Fig. 4B). Drainage of fluid collections can be performed with image guidance (ultrasound or CT). Autogenous Fat Injection Buttock augmentation using autogenous fat (i.e., autologous augmentation) has been increasingly used recently, because of its natural appearance and availability (Fig. 5A). The use of fat allows a greater degree of augmentation than implants and leaves less evident scarring. In this procedure, fat is suctioned from another body part (e.g., from lower back, flanks, or trochanteric regions). The collected fat is then transferred to syringes and injected into the buttocks through multiple small incisions [15]. Liposuction of the excess fat of the lower back and flanks (low back body lift) helps with contouring of the buttocks [15]. Many surgeons prefer performing liposuction and lipofilling of the buttocks because of these advantages, as well as the relatively high complication rate of buttock implant [16]. Complications of fat augmentation include cellulitis, seroma, infection, donor-site ischemia or fluid accumulation, fat embolism, transient sciatic paresthesias, and partial reabsorption of fat grafts [16]. Hematomas and seromas are common in the postoperative period. Over time, calcifications may develop in association with fat necrosis (Fig. 5B). Major complications are more common with a larger amount of fat transfer (> 1000 mL per buttock) [16].
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Imaging of Cosmetic Plastic Implants Gluteal Filler Injection Liquid injectable silicone has long been used for soft-tissue augmentation as a permanent filler (Fig. 6). Although widely used in the 1960s, as noted already, the FDA banned it in 1992 because of its complications [17]. It is currently approved only for intraocular injection for treatment of severe retinal detachment in the United States. Liquid silicone is still legally used in some European countries. Minor complications include injectionsite reaction, erythema, edema, scarring, and palpable small nodules. Major complications include ulceration, cellulitis, disfiguration, painful granuloma formation, silicone migration, and even life-threatening hypercalcemia or pneumonitis [17, 18]. Granulomatous reactions may occur weeks to decades after injection. The incidence of granuloma formation is lower in patients injected with pure sterile medical-grade silicone but still may occur in up to 20% of patients. Silicone migration is more common with larger-volume injections [18]. Liquid silicone is as dense as or slightly denser than soft tissue and is isointense to hypointense to water on T2-weighted images, depending on oil viscosity. Chemical shift artifact and fat suppression may also occur on MRI sequences [19]. A few other types of injectable soft-tissue fillers have been used outside the United States for buttock augmentation. For instance, Macrolane (Q-Med) is a stabilized hyaluronic acid gel that may be used as a buttock and facial filler [20]. Gel degradation results in reduction in volume with time, which can be assessed using MRI [20]. Hyaluronic acid fillers have a CT density near that of fluid and MR signal characteristics closer to those of water [19]. Abdominoplasty and Body Lift Abdominoplasty is a body lift and contouring procedure to create a more flat, firm abdomen. It is performed to remove excess fat and sagging skin that may become pronounced as a result of significant weight loss after pregnancy or bariatric surgery [21]. Over 160,000 abdominoplasty procedures were performed in 2013 in the United States [9]. Standard abdominoplasty involves an incision above the pubis from hip to hip, separates the umbilicus from the skin, removes excess tissue, and reapproximates the recti muscles with sutures. On CT, recti muscles may appear clumped along the midline [21, 22] (Fig. 7A).
Other types of body lift procedures include upper back lift, lower back lift, thigh lift, and brachioplasty (arm lift). Lower back lift is commonly performed with autogenous gluteal augmentation [21]. Early potential complications include seroma (10%), hematoma, delayed healing, skin flap necrosis, fat necrosis, and pulmonary embolism [23] (Fig. 7). Late complications include localized fat excess and an unsatisfactory scar or an unsatisfactory appearance of the umbilicus [23]. Penile Implant Penile implants are an effective and reliable treatment of erectile dysfunction after failure of medical therapy. Up to 25,000 of American men with erectile dysfunction undergo penile implant placement each year [24]. Complications of penile implant placement are uncommon but may be serious. Diagnosis of complications on the basis of history and physical examination is limited, and imaging is requested for detection of complications and visualization of implant details [25]. Implants are often incidentally noted on imaging of the abdomen and pelvis and may or may not be functioning. The main type of penile implant is the hydraulic prosthesis, which consists of two types: three-piece inflatable and two-piece inflatable implants [25, 26]. The three-piece inflatable implant is the most widely used and yields the best results in terms of rigidity and flaccidity [25]. The three-piece inflatable device consists of a pair of cylinders that are inserted inside each corpus cavernosum; a pump that is placed in the scrotum, between the testicles; a reservoir that is surgically placed in the perivesical space; and connecting silicone tubing (Fig. 8). Manual compression of the scrotal pump transfers fluid to cylinders, resulting in erection, and release of the valve results in passive flow of fluid back to the reservoir through the silicone tubing. The two-piece prosthesis consists of two cylinders and a pump placed in the scrotum. The hydraulic system is usually filled with normal saline [25, 26]. Semirigid penile prostheses are composed of two paired cylinders that are inserted into both corpora cavernosa. These can have metallic, silicone, and polyethylene components [25]. Ultrasound may be helpful in evaluation of reservoir and cylinders, although findings tend to be limited [27]. Recent literature advocates the use of CT and MRI but not ultrasound as the initial imaging modal-
ity [25, 26, 28, 29]. CT can be used to assess the reservoir in the pelvis, which appears as a round or oval cystic mass with hyperdense walls and internal fluid density. The presence of internal folds and the loss of the normal round or oval shape in the deflated state may be suggestive of a leak or wall rupture, which is the most common complication of penile implant placement [28] (Fig. 9A). Placement of the reservoir in the pelvis may be associated with pelvic organ damage, including injury to the bladder, colon, or small bowel (Fig. 9B). Reservoir migration to the bladder, scrotum, bowel loops, or ileal conduit is a less common complication [28] (Fig. 9C). MRI can be used to evaluate the reservoir and assess the tunica and cylinders during the erect and flaccid states [25]. Axial and coronal T1- and T2-weighted images of the pelvis are acquired using a body coil, followed by triplanar high-spatial-resolution (matrix size, ≥ 200), small-FOV, thin-slice (ideally 3 mm) T2-weighted spin-echo sequences in three orthogonal planes, in both the flaccid and erect states. Then, axial T1weighted fat-saturated images of the pelvis are acquired before and after IV administration of gadolinium contrast material. Cylinder buckling is thought to be a cause of prolonged penile pain and is readily detectable on MRI [25, 29]. Other conditions detectable on MRI include cylinder migration and location discrepancy between the right and left cylinders, infection, erosion, fistula, corporal distortion, and hypermobile glans. Inadequate cylinder size results in bowing or ventral deflection of the glans, which is called supersonic transporter deformity. Fibrous sheath formation around the reservoir can limit reservoir deflation. Crossover and dilatation of cavernosal components are other detectable conditions on MRI [25, 29]. Imaging can be performed with the implantable device inflated or deflated (Fig. 8). MRI can elucidate the cause of pain and inability to deflate the prosthesis after surgery (Fig. 9D). MRI was shown to be 100% sensitive and 92% specific for evaluation of prolonged pain after penile prosthesis placement in 65 symptomatic and asymptomatic patients [25]. All patients with prolonged pain had a pathologic finding on MRI, with cylinder buckling being the most common finding [25]. A small amount of fluid and stranding can be seen around the implant in the postoperative state, whereas a larger amount of fluid and stranding is suggestive of infection
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Yahyavi-Firouz-Abadi et al. (Fig. 9E). There is consensus on the need for removal of clinically infected penile implants [24]. Penile implants are generally safe in 1.5-T MRI systems. However, a few types of malleable implants (Duraphase and Omniphase, both from Dacomed) should not be used owing to their ferromagnetic components [30]. Testicular Prosthesis Testicular prosthesis after orchiectomy or in patients with cryptorchidism or testicular agenesis is a relatively safe procedure that has been in use since 1939 [31]. Different types of implants have been developed including metallic, foam, methyl methacrylate, glass, and silicone. Silicone gel–filled prostheses were discontinued in the United States in 1995 because of safety concerns, as noted already. The only currently FDA-approved implant available in the United States has a silicone elastomer shell and is filled with saline. In Europe, silicone prostheses that are filled with silicone gel or soft silicone elastomer are also available [31]. Testicular implants may be encountered on routine imaging examinations and should not be mistaken for a normal testicle or for a diffusely infiltrated testicle. Occasionally, imaging may be performed to assess for implant integrity. On MRI, the silicone-shell saline-filled implant generally appears hypointense on T1-weighted images and hyperintense on T2-weighted images. Solid silicone elastomer implants resemble a normal testicle (hypointense on T1-weighted images and slightly hyperintense on T2-weighted images), except for chemical shift artifact in the frequency-encoding direction. A silicone gel– filled prosthesis appears dark on both T1and T2-weighted images and may resemble a mass [32]. On CT, a testicular prosthesis appears as an ovoid fluid collection with a hyperdense wall (Fig. 10A). Shell calcification may occur, similar to the calcification commonly seen around breast implants. On ultrasound, a saline-filled implant appears as an ovoid anechoic structure (Fig. 10B). Silicone gel implants have an anechoic center with a well-defined regular contour. Reverberation echoes may be seen just deep to the echogenic interface with surrounding soft tissue [33]. Ultrasound or MRI (or both) may be performed to assess the integrity of the testicular prosthesis. Testicular prostheses are very su-
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perficial and easily imaged with ultrasound, unlike subpectoral breast implants. A stepladder pattern of multiple parallel lines in the implant may represent intracapsular rupture of a silicone gel implant, similar to what is seen with silicone breast implants [33]. MRI is a more accurate method of showing the intracapsular implant rupture, and diagnostic findings of intracapsular rupture include the linguine sign [34]. Complications of testicular implants are similar to those of breast implants, including pain, rupture, fibrous capsule formation, and contracture. Scrotal contraction and migration into the inguinal canal are less common complications [33]. Conclusion Radiologists commonly encounter the postoperative appearance of various implants and cosmetic techniques in the body on routine imaging examinations. Understanding their normal appearance can prevent unnecessary additional imaging. Also, radiologists may be asked to evaluate for radiologic evidence of postoperative complications and prosthesis failure. In this article, the imaging spectrum of the normal appearance and complications of body implants and cosmetic techniques has been discussed, to allow a better understanding of their CT, MRI, and ultrasound appearances. References 1. Benito-Ruiz J, Raigosa JM, Manzano-Surroca M, Salvador L. Male chest enhancement: pectoral implants. Aesthetic Plast Surg 2008; 32:101–104 2. Saour S, Shaaban H, McPhail J, McArthur P. Customised silicone prostheses for the reconstruction of chest wall defects: technique of manufacture and final outcome. J Plast Reconstr Aesthet Surg 2008; 61:1205–1209 3. Benito-Ruiz J. Buttock implants for male chest enhancement. Plast Reconstr Surg 2003; 112:1951 4. Schatz CJ, Ginat DT. Imaging of cosmetic facial implants and grafts. AJNR 2013; 34:1674–1681 5. Johnson PE. Refining silicone implant correction of pectus excavatum through computed tomography. Plast Reconstr Surg 1996; 97:445–449 6. Scaranelo AM, de Fatima Ribeiro Maia M. Sonographic and mammographic findings of breast liquid silicone injection. J Clin Ultrasound 2006; 34:273–277 7. Venkataraman S, Hines N, Slanetz PJ. Challenges in mammography. Part 2. Multimodality review of breast augmentation–imaging findings and complications. AJR 2011; 197:[web]W1031– W1045
8. Vergara R, Amezcua H. Intramuscular gluteal implants: 15 years’ experience. Aesthet Surg J 2003; 23:86–91 9. American Society for Aesthetic Plastic Surgery. 2013 Cosmetic Surgery National Data Bank statistics. www.surgery.org/sites/default/files/Stats2013_3. pdf. Accessed December 9, 2014 10. Mofid MM, Gonzalez R, de la Peña JA, Mendieta CG, Senderoff DM, Jorjani S. Buttock augmentation with silicone implants: a multicenter survey review of 2226 patients. Plast Reconstr Surg 2013; 131:897–901 11. Senderoff DM. Buttock augmentation with solid silicone implants. Aesthet Surg J 2011; 31:320– 327 12. Flores-Lima G, Eppley BL, Dimas JR, Navarro DE. Surgical pocket location for gluteal implants: a systematic review. Aesthetic Plast Surg 2013; 37:240–245 13. Gonzalez R. Gluteal implants: the “XYZ” intramuscular method. Aesthet Surg J 2010; 30:256– 264 14. Darouiche RO. Treatment of infections associated with surgical implants. N Engl J Med 2004; 350:1422–1429 15. Ali A. Contouring of the gluteal region in women: enhancement and augmentation. Ann Plast Surg 2011; 67:209–214 16. Bruner TW, Roberts TL 3rd, Nguyen K. Complications of buttocks augmentation: diagnosis, management, and prevention. Clin Plast Surg 2006; 33:449–466 17. Camuzard O, Dumas P, Foissac R, et al. Severe granulomatous reaction associated with hypercalcemia occurring after silicone soft tissue augmentation of the buttocks: a case report. Aesthetic Plast Surg 2014; 38:95–99 18. Lopiccolo MC, Workman BJ, Chaffins ML, Kerr HA. Silicone granulomas after soft-tissue augmentation of the buttocks: a case report and review of management. Dermatol Surg 2011; 37:720–725 19. Ginat DT, Schatz CJ. Imaging features of midface injectable fillers and associated complications. AJNR 2013; 34:1488–1495 20. Camenisch CC, Tengvar M, Heden P. Macrolane for volume restoration and contouring of the buttocks: magnetic resonance imaging study on localization and degradation. Plast Reconstr Surg 2013; 132:522e–529e 21. Shermak MA. Body contouring. Plast Reconstr Surg 2012; 129:963e–978e 22. Frank SJ, Flusberg M, Friedman S. CT appearance of common cosmetic and reconstructive surgical procedures and their complications. Clin Radiol 2013; 68:e72–e78 23. Stewart KJ, Stewart DA, Coghlan B, Harrison DH, Jones BM, Waterhouse N. Complications of
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Imaging of Cosmetic Plastic Implants 278 consecutive abdominoplasties. J Plast Reconstr Aesthet Surg 2006; 59:1152–1155 24. Darouiche RO, Bella AJ, Boone TB, et al. North American consensus document on infection of penile prostheses. Urology 2013; 82:937–942 25. Moncada I, Jara J, Cabello R, Monzo JI, Hernández C. Radiological assessment of penile prosthesis: the role of magnetic resonance imaging. World J Urol 2004; 22:371–377 26. Cohan RH, Dunnick NR, Carson CC. Radiology of penile prostheses. AJR 1989; 152:925–931 27. Suarez G, Baum N. Ultrasonography in evalua-
tion of mechanical problems of inflatable penile prosthesis. Urology 1987; 30:388–389 28. Brook OR, Ghersin E, Guralnik L, Kaftori JK, Amendola MA, Engel A. Penile prosthesis reservoir: an imaging pitfall. Clin Radiol 2008; 63:343–347 29. Kirkham A. MRI of the penis. Br J Radiol 2012; 85:S86–S93 30. Lowe G, Smith RP, Costabile RA. A catalog of magnetic resonance imaging compatibility of penile prostheses. J Sex Med 2012; 9:1482–1487 31. Turek PJ, Master VA. Safety and effectiveness of a
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new saline filled testicular prosthesis. J Urol 2004; 172:1427–1430 32. Semelka R, Anderson M, Hricak H. Prosthetic testicle: appearance at MR imaging. Radiology 1989; 173:561–562 33. Goyal N, Floyd MS Jr, Agarwal SK, De Bolla AR. Sonographic findings of testicular prosthesis rupture. Clin Radiol 2011; 66:383–384 34. Hage JJ, Taets van Amerongen AH, Van Diest PJ. Rupture of silicone gel filled testicular prosthesis: causes, diagnostic modalities and treatment of a rare event. J Urol 1999; 161:467–471
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Fig. 1—Silicone chest wall implants. A, Axial unenhanced CT image of lower chest shows bilateral silicone pectoral implants in 56-year-old man undergoing workup for detection of urolithiasis. B, Axial contrast-enhanced CT image of chest shows custom-made silicone implant improving chest wall deformity in 28-year-old woman with pectus excavatum. C, Axial IV contrast-enhanced CT image of chest in 39-year-old man with right pectoral implant infection who developed abscess and myositis of right pectoral muscle shows fat stranding in subcutaneous fat; right pectoral muscle has hypoenhancement compared with left. Both implants were removed and abscess was drained.
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Fig. 2—23-year-old man with history of bilateral free silicone injection for pectoral augmentation. A, Axial IV contrast-enhanced CT image of chest shows stranding and enlargement of bilateral pectoral muscles. Silicone is also evident in subcutaneous tissues. B, Mammogram was performed because of palpable lump in right breast. Mediolateral oblique view of right breast shows BB marker at palpable site. Multiple round dense masses represent free injected silicone granulomas (arrow).
Fig. 3—Different surgical pockets for gluteal implant placement are outlined on axial T1-weighted image of pelvis. Orange line delineates borders of right gluteus maximus muscle; light blue dotted line marks right sciatic nerve deep to gluteus maximus muscle; dark blue dotted line illustrates fascia; green line in left buttock shows subfascial pocket, which is superficial; red line shows intramuscular pocket; and yellow line shows submuscular pocket, which is in close contact with sciatic nerve.
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Fig. 4—Complications of gluteal silicone implant. A, Axial IV contrast-enhanced CT image of pelvis in 29-year-old woman with bilateral postoperative seromas 1 week after gluteal implant placement shows rimenhancing collections surrounding both implants, with only minimal fat stranding in subcutaneous fat. B, Axial T1-weighted fat-saturated contrast-enhanced MR image of pelvis in 45-year-old man with infected late seroma 1 year after bilateral gluteal implant placement shows bilateral subfascial gluteal implants in place, with rim-enhancing fluid collection surrounding left implant, as well as fat stranding and enhancement of gluteal subcutaneous fat surrounding left implant. Collection was subsequently drained.
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Fig. 5—Autogenous gluteal augmentation. A, Axial unenhanced CT image of pelvis shows postoperative appearance of autogenous gluteal augmentation and circumferential body lift in 51-year-old woman 1 week after operation. Two fat-density masses in buttocks represent gluteal augmentation, with extensive fat stranding and infiltration, as well as small surrounding fluid collections, which are seromas. Fat stranding in anterior abdominal wall is result of circumferential body lift and liposuction. B, Axial unenhanced CT of pelvis in same patient 8 years later shows two fat-density masses in both buttocks, with round area of calcification in left buttock representing fat necrosis.
Fig. 6—Axial IV contrast-enhanced CT image of pelvis in 22-year-old man who had received gluteal free silicone injection shows extensive stranding and soft-tissue density material and nodules in both buttocks.
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Fig. 7—Abdominoplasty and body lift complication. A, Axial IV contrast-enhanced CT image of abdomen in 45-year-old woman who presented with increasing pain in anterior abdominal wall and fever 2 months after circumferential trunk liposuction and abdominoplasty shows large rim-enhancing fluid collection in anterior abdominal wall, representing infected seroma. Patient underwent incision, drainage, and treatment with doxycycline as sclerosing agent. Note that after abdominoplasty, recti muscles appear approximated or clumped together (asterisks). B, Axial CT image of abdomen after oral and IV contrast administration in 41-year-old woman 1 month after circumferential body lift shows postoperative seroma. Rimenhancing fluid collections (asterisks) are evident in subcutaneous tissue of back, with foci of gas. Clinical findings were suggestive of seroma, rather than abscess, and collections later resolved.
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Fig. 8—CT and MRI appearance of penile prosthesis. A, Axial IV contrast-enhanced CT image of pelvis in 45-year-old man shows inflated penile cylinders placed in corpora cavernosa. Note slight discrepancy in cylinder placement and disuse atrophy of pelvic muscles in this patient with history of poorly controlled diabetes and bilateral lower extremity amputations. B, Coronal unenhanced CT image of pelvis in 61-year-old man shows three-piece inflatable penile implant. Ovoid saline-filled reservoir (asterisk) is evident in pelvis, and dense silicone tubing extends to pump (arrowhead) in scrotum. Note cylinders and associated tubing in corpora cavernosa (arrow). C, Sagittal T2-weighted high-spatial-resolution image of pelvis in 64-year-old man shows normal appearance of three-piece inflatable implant 6 months after prosthesis placement. Arrow denotes deflated cylinders, which may have folds. Normal pump is evident in scrotum (asterisk). D, Coronal T2-weighted high-spatial-resolution image in same patient as C after inflation of cylinders shows symmetric inflation with no evidence of rupture, kink, deformity, or fluid collection.
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Fig. 9—Complications of penile prosthesis. A, Axial IV contrast-enhanced CT of pelvis in 83-year-old man with failed penile prosthesis shows severe narrowing, irregularity, and disruption of walls of penile cylinders, which are deflated; reservoir in pelvis was also deflated. These findings likely represent prosthesis failure due to leak. Patient underwent removal of implant and placement of new prosthesis. B, Axial unenhanced CT image of lower abdomen in 46-year-old man with small-bowel injury secondary to reservoir placement shows reservoir in pelvis (asterisk) with surrounding free intraperitoneal gas (arrowhead). Patient presented with fever, abdominal pain, peritoneal signs, and crepitus over site of his reservoir several days after operation. There is extensive mesenteric fat stranding surrounding loops of small bowel adjacent to reservoir. Gas extends to subcutaneous tissue (arrow) on left side of abdominal wall. Patient underwent removal of implant, peritoneal washout, small-bowel resection, and loop ileostomy. C, Axial IV contrast-enhanced CT image of pelvis in 49-year-old man with colonic injury during penile prosthesis reservoir placement shows deflated reservoir (arrow) partially in colon, where tubing and reservoir have migrated. There is dilatation of proximal loops of bowel. D, Sagittal T2-weighted high-spatial-resolution MR image of pelvis in 67-year-old man after inflatable prosthesis placement shows inflated cylinders (arrow) with no evidence of associated hemorrhage or fluid collection. Patient inflated prosthesis within few days after placement and was not able to deflate it and presented with severe pain. MRI of pelvis was performed mainly to differentiate hemorrhage surrounding cylinders from inflated cylinders. Implant was manually deflated in operating room, and adhesions were found surrounding scrotal pump (asterisk). Release of adhesions resulted in proper implant function. E, Coronal T2-weighted high-spatial-resolution MR image of penis and scrotum in 71-year-old man with penile implant infection 2 months after implant placement shows small amount of fluid (arrows) in both hemiscrotums, surrounding pump (asterisk) and cylinders. Patient was not able to inflate cylinders during MRI owing to severity of pain. Patient underwent implant removal, washout, and placement of new three-piece implant, resulting in resolution of symptoms.
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Fig. 10—Testicular prosthesis in 25-year-old man with history of seminoma and right orchiectomy. A, Coronal unenhanced CT image of pelvis shows saline-filled testicular prosthesis (asterisk) with dense rim of silicone. Note normal testicle on left. B, Sagittal ultrasound image of right scrotum shows ovoid anechoic implant with posterior acoustic enhancement.
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Special Articles Review
Imaging of Cosmetic Plastic Procedures and Implants in the Body and Their Potential Complications Noushin Yahyavi-Firouz-Abadi1,2 Christine O. Menias 3 Sanjeev Bhalla1 Cary Siegel1 Gabriela Gayer4 Douglas S. Katz 5 Yahyavi-Firouz-Abadi N, Menias CO, Bhalla S, Siegel C, Gayer G, Katz DS
OBJECTIVE. Cosmetic plastic surgery procedures, as well as implants, are increasingly being performed. These implants are often encountered on routine imaging examinations, and radiologists are often asked to evaluate for complications or evidence of failure. Pectoral augmentation, gluteal augmentation, body lift and abdominoplasty, and penile and testicular prostheses are reviewed in this article. CONCLUSION. The typical appearance of common cosmetic implants and cosmetic techniques used in the human body is presented, along with the imaging spectrum of their potential complications.
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Keywords: abdominoplasty, augmentation, body lift, gluteal, pectoral, penile, testicular DOI:10.2214/AJR.14.13516 Received July 19, 2014; accepted after revision September 2, 2014. Based on a presentation at the Radiological Society of North America 2013 annual meeting, Chicago, Il. 1
Mallinckrodt Institute of Radiology, Washington University School of Medicine, St. Louis, MO.
2 Present address: The Russell H. Morgan Department of Radiology and Radiologic Science, The Johns Hopkins Medical Institute, Baltimore, MD. 3 Department of Radiology, Mayo Clinic, 13400 E Shea Blvd, Scottsdale, AZ 85259. Address correspondence to C. O. Menias ([email protected]). 4 Department of Radiology, Stanford University Medical Center, Stanford, CA. 5 Department of Radiology, Winthrop-University Hospital, Mineola, NY.
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wide variety of cosmetic plastic surgery techniques and implants have been developed for improving the appearance of or restoring function to the human body. Recently, additional materials and techniques have been developed for such procedures. Radiologists are involved in the preoperative assessment, planning, and evaluation of postoperative failure and other complications of such cosmetic surgical implants and techniques. Commonly, postsurgical changes and implants represent incidental findings on routine imaging examinations. Radiologists need to be familiar with the spectrum of the normal postoperative appearance of such implants and procedures on different imaging modalities, so as not to mistake them for pathology, particularly neoplasm or infection. In addition, radiologists are often asked to perform and interpret a dedicated imaging examination to evaluate for implant failure or complications. Imaging of female breast augmentation and implants and their complications has been extensively discussed in the literature. However, to our knowledge, imaging features and complications of male chest augmentation, cosmetic body lift techniques, buttock augmentation, and penile and testicular prostheses have not been well studied. After reading this article, radiologists will be more familiar with the expected imaging appearances of implants and cosmetic techniques in the body and the spectrum of imaging fea-
tures of implant complications or failure, with an emphasis on CT and MRI findings. Male Chest Enhancement (Pectoral Augmentation) Pectoral Implant Chest augmentation or enhancement is increasingly performed in men [1]. Most patients are those who are unable or unwilling to build their pectoral muscles with exercise [1]. Less commonly, it is performed in patients with congenital or acquired deformities of the chest wall. Examples of the latter include unilateral congenital absence of the pectoral muscle (Poland syndrome), pectoral denervation due to brachial plexus injury, muscle injury related to sports, pectus excavatum, and postsurgical chest wall deformities [1, 2]. Implants are typically available through manufacturers and are occasionally custom made for a specific patient [1, 2]. Buttock implants have also been used for pectoral augmentation, although they often do not fill the cranial portion of the pectoral muscle [3]. Implants may be placed in a transverse or oblique position depending on the underlying deformity or defect. Pectoral implants are made of silicone rubber, which is easily customizable and has a soft, pliable consistency [1, 2]. Silicone rubber has a variable CT appearance, typically denser than soft tissue but less dense than bone; on MRI, silicone rubber is hypointense on both T1- and T2-weighted images [4] (Fig. 1A).
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Yahyavi-Firouz-Abadi et al. Presurgical planning for customized implants can be performed using either an alginate impression of the chest wall or a 3D reconstruction from a chest CT [2]. CT reconstruction is somewhat more expensive but highly accurate [2]. Rapid prototyping can be done to build a model directly from computer data [2]. This is especially useful in patients with deformities such as pectus excavatum [2, 5] (Fig. 1B). Complications of pectoral augmentation include seroma, hematoma, malposition, extrusion or displacement of the implant, infection, capsular retraction, visibility of the edges of the implant, and over- or undercorrection. Capsular retraction happens as a result of foreign-body reaction and results in deformity and hardening; these are detected clinically and not typically seen on imaging. Some implants are reported to be associated with less implant displacement, including those with a textured surface, surgical stitching, or incorporated holes for ingrowth [2]. CT features that suggest infection include fat stranding, abnormal fluid collections, and hypoenhancement of the pectoral muscle (Fig. 1C). Chest Wall Augmentation Using Free Silicone Injection Free silicone injection was commonly used in the past for breast augmentation in women, but it was banned by the U.S. Food and Drug Administration (FDA) in 1992 because of safety concerns and ineffectiveness [6]. Nevertheless, imaging features of this type of breast augmentation may still be encountered in older patients and immigrants. Rarely, this type of augmentation may be seen in patients who have undergone illegal cosmetic surgery procedures in the United States by unlicensed practitioners. Free silicone injection in men is encountered much less commonly than in women. Complications of free silicone injection include silicone granulomas, fibrosis, and lymphadenopathy [6, 7]. On mammography, multiple dense nodular masses are usually seen. On CT, silicone granulomas appear as soft-tissue nodules with associated fat infiltration (Fig. 2). On MRI, these nodules are hypointense on T1-weighted images, hyperintense on T2-weighted images, and hyperintense on silicone-sensitive sequences [6, 7]. Autogenous fat transfer to the chest wall after liposuction (lipofilling) is also used for pectoral augmentation. It has an imaging appearance similar to breast fat augmentation in women.
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Gluteal Augmentation Gluteal augmentation was introduced in 1965 with the insertion of breast prostheses in the buttocks and is now one of the fastest-growing fields in plastic surgery [8]. According to statistics from the American Society of Aesthetic Plastic Surgery [9], 11,527 patients underwent buttock augmentation procedures in 2013, as compared with 614 in 2002. Gluteal augmentation can be performed using different techniques, such as solid silicone implant placement, autogenous fat augmentation, and filler injection. Gluteal Implant Placement Gluteal implant placement yields the best long-term aesthetic results and is increasingly being performed in the United States [10]. Solid silicone elastomer implants are the sole implants approved by the FDA for buttock augmentation. Most of the literature about gluteal implant placement is from South and Central America, where the use of cohesive silicone gel is preferred over solid silicone elastomer [10, 11]. Solid silicone elastomer has the ability to increase gluteal tone in patients with ptosis, congenital or acquired gluteal deformities, and asymmetry [8]. Different surgical techniques have been described for implant placement, including the use of subcutaneous, subfascial, intramuscular, and submuscular pockets [12] (Fig. 3). Surgical complications including seroma, dehiscence, infection, implant visibility, and implant displacement are reported more frequently with superficial implant placement. Submuscular (between the gluteus maximus and medius) implant placement has the risk of damage to the sciatic nerve and is rarely performed [12] (Fig. 3). Because of submuscular anatomic limitations, only small implants can be placed, which cannot extend beyond the lower edge of the pyramidal muscle, resulting in a “double-buttock” appearance. In the intramuscular method, the gluteal muscle is bisected, and the implant is placed in between the layers. Intramuscular placement using the “XYZ” method has recently been described and is reported to have the lowest complication rate [13]. In this method, the surgeon splits the gluteus maximus muscle into two equal halves with anatomic reference points to determine the ideal implant plane and guide symmetric muscle detachment at an adequate depth [13]. A systematic review of the literature reports the complication rates for different locations as follows: 55% for subfascial, 18% for intra-
muscular, and 18% for submuscular versus 13% for intramuscular XYZ methods [12]. Complications include seroma (as well as late seroma), hematoma, dehiscence, infection, capsular contracture, pain, implant visibility, and implant rupture. The appearance of gluteal silicone rubber implants on CT and MRI is the same as previously discussed for pectoral implants. As with other implants, both hematomas and abscesses may present with fluid collections on imaging (Fig. 4). When fat stranding is seen, infection should be suspected. For cosmetic implants (buttock, pectoral, and mammary), removal is the mainstay of treatment [14]. However, management depends on clinical findings and severity of infection. As shown in Figure 1C, in a patient with an infected pectoral implant—signs of which included abscess, myositis, fever, and leukocytosis—the implant was removed. By contrast, minor infection, such as superimposed infection in a postoperative seroma, could potentially be managed initially with percutaneous drainage (Fig. 4B). Drainage of fluid collections can be performed with image guidance (ultrasound or CT). Autogenous Fat Injection Buttock augmentation using autogenous fat (i.e., autologous augmentation) has been increasingly used recently, because of its natural appearance and availability (Fig. 5A). The use of fat allows a greater degree of augmentation than implants and leaves less evident scarring. In this procedure, fat is suctioned from another body part (e.g., from lower back, flanks, or trochanteric regions). The collected fat is then transferred to syringes and injected into the buttocks through multiple small incisions [15]. Liposuction of the excess fat of the lower back and flanks (low back body lift) helps with contouring of the buttocks [15]. Many surgeons prefer performing liposuction and lipofilling of the buttocks because of these advantages, as well as the relatively high complication rate of buttock implant [16]. Complications of fat augmentation include cellulitis, seroma, infection, donor-site ischemia or fluid accumulation, fat embolism, transient sciatic paresthesias, and partial reabsorption of fat grafts [16]. Hematomas and seromas are common in the postoperative period. Over time, calcifications may develop in association with fat necrosis (Fig. 5B). Major complications are more common with a larger amount of fat transfer (> 1000 mL per buttock) [16].
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Imaging of Cosmetic Plastic Implants Gluteal Filler Injection Liquid injectable silicone has long been used for soft-tissue augmentation as a permanent filler (Fig. 6). Although widely used in the 1960s, as noted already, the FDA banned it in 1992 because of its complications [17]. It is currently approved only for intraocular injection for treatment of severe retinal detachment in the United States. Liquid silicone is still legally used in some European countries. Minor complications include injectionsite reaction, erythema, edema, scarring, and palpable small nodules. Major complications include ulceration, cellulitis, disfiguration, painful granuloma formation, silicone migration, and even life-threatening hypercalcemia or pneumonitis [17, 18]. Granulomatous reactions may occur weeks to decades after injection. The incidence of granuloma formation is lower in patients injected with pure sterile medical-grade silicone but still may occur in up to 20% of patients. Silicone migration is more common with larger-volume injections [18]. Liquid silicone is as dense as or slightly denser than soft tissue and is isointense to hypointense to water on T2-weighted images, depending on oil viscosity. Chemical shift artifact and fat suppression may also occur on MRI sequences [19]. A few other types of injectable soft-tissue fillers have been used outside the United States for buttock augmentation. For instance, Macrolane (Q-Med) is a stabilized hyaluronic acid gel that may be used as a buttock and facial filler [20]. Gel degradation results in reduction in volume with time, which can be assessed using MRI [20]. Hyaluronic acid fillers have a CT density near that of fluid and MR signal characteristics closer to those of water [19]. Abdominoplasty and Body Lift Abdominoplasty is a body lift and contouring procedure to create a more flat, firm abdomen. It is performed to remove excess fat and sagging skin that may become pronounced as a result of significant weight loss after pregnancy or bariatric surgery [21]. Over 160,000 abdominoplasty procedures were performed in 2013 in the United States [9]. Standard abdominoplasty involves an incision above the pubis from hip to hip, separates the umbilicus from the skin, removes excess tissue, and reapproximates the recti muscles with sutures. On CT, recti muscles may appear clumped along the midline [21, 22] (Fig. 7A).
Other types of body lift procedures include upper back lift, lower back lift, thigh lift, and brachioplasty (arm lift). Lower back lift is commonly performed with autogenous gluteal augmentation [21]. Early potential complications include seroma (10%), hematoma, delayed healing, skin flap necrosis, fat necrosis, and pulmonary embolism [23] (Fig. 7). Late complications include localized fat excess and an unsatisfactory scar or an unsatisfactory appearance of the umbilicus [23]. Penile Implant Penile implants are an effective and reliable treatment of erectile dysfunction after failure of medical therapy. Up to 25,000 of American men with erectile dysfunction undergo penile implant placement each year [24]. Complications of penile implant placement are uncommon but may be serious. Diagnosis of complications on the basis of history and physical examination is limited, and imaging is requested for detection of complications and visualization of implant details [25]. Implants are often incidentally noted on imaging of the abdomen and pelvis and may or may not be functioning. The main type of penile implant is the hydraulic prosthesis, which consists of two types: three-piece inflatable and two-piece inflatable implants [25, 26]. The three-piece inflatable implant is the most widely used and yields the best results in terms of rigidity and flaccidity [25]. The three-piece inflatable device consists of a pair of cylinders that are inserted inside each corpus cavernosum; a pump that is placed in the scrotum, between the testicles; a reservoir that is surgically placed in the perivesical space; and connecting silicone tubing (Fig. 8). Manual compression of the scrotal pump transfers fluid to cylinders, resulting in erection, and release of the valve results in passive flow of fluid back to the reservoir through the silicone tubing. The two-piece prosthesis consists of two cylinders and a pump placed in the scrotum. The hydraulic system is usually filled with normal saline [25, 26]. Semirigid penile prostheses are composed of two paired cylinders that are inserted into both corpora cavernosa. These can have metallic, silicone, and polyethylene components [25]. Ultrasound may be helpful in evaluation of reservoir and cylinders, although findings tend to be limited [27]. Recent literature advocates the use of CT and MRI but not ultrasound as the initial imaging modal-
ity [25, 26, 28, 29]. CT can be used to assess the reservoir in the pelvis, which appears as a round or oval cystic mass with hyperdense walls and internal fluid density. The presence of internal folds and the loss of the normal round or oval shape in the deflated state may be suggestive of a leak or wall rupture, which is the most common complication of penile implant placement [28] (Fig. 9A). Placement of the reservoir in the pelvis may be associated with pelvic organ damage, including injury to the bladder, colon, or small bowel (Fig. 9B). Reservoir migration to the bladder, scrotum, bowel loops, or ileal conduit is a less common complication [28] (Fig. 9C). MRI can be used to evaluate the reservoir and assess the tunica and cylinders during the erect and flaccid states [25]. Axial and coronal T1- and T2-weighted images of the pelvis are acquired using a body coil, followed by triplanar high-spatial-resolution (matrix size, ≥ 200), small-FOV, thin-slice (ideally 3 mm) T2-weighted spin-echo sequences in three orthogonal planes, in both the flaccid and erect states. Then, axial T1weighted fat-saturated images of the pelvis are acquired before and after IV administration of gadolinium contrast material. Cylinder buckling is thought to be a cause of prolonged penile pain and is readily detectable on MRI [25, 29]. Other conditions detectable on MRI include cylinder migration and location discrepancy between the right and left cylinders, infection, erosion, fistula, corporal distortion, and hypermobile glans. Inadequate cylinder size results in bowing or ventral deflection of the glans, which is called supersonic transporter deformity. Fibrous sheath formation around the reservoir can limit reservoir deflation. Crossover and dilatation of cavernosal components are other detectable conditions on MRI [25, 29]. Imaging can be performed with the implantable device inflated or deflated (Fig. 8). MRI can elucidate the cause of pain and inability to deflate the prosthesis after surgery (Fig. 9D). MRI was shown to be 100% sensitive and 92% specific for evaluation of prolonged pain after penile prosthesis placement in 65 symptomatic and asymptomatic patients [25]. All patients with prolonged pain had a pathologic finding on MRI, with cylinder buckling being the most common finding [25]. A small amount of fluid and stranding can be seen around the implant in the postoperative state, whereas a larger amount of fluid and stranding is suggestive of infection
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Yahyavi-Firouz-Abadi et al. (Fig. 9E). There is consensus on the need for removal of clinically infected penile implants [24]. Penile implants are generally safe in 1.5-T MRI systems. However, a few types of malleable implants (Duraphase and Omniphase, both from Dacomed) should not be used owing to their ferromagnetic components [30]. Testicular Prosthesis Testicular prosthesis after orchiectomy or in patients with cryptorchidism or testicular agenesis is a relatively safe procedure that has been in use since 1939 [31]. Different types of implants have been developed including metallic, foam, methyl methacrylate, glass, and silicone. Silicone gel–filled prostheses were discontinued in the United States in 1995 because of safety concerns, as noted already. The only currently FDA-approved implant available in the United States has a silicone elastomer shell and is filled with saline. In Europe, silicone prostheses that are filled with silicone gel or soft silicone elastomer are also available [31]. Testicular implants may be encountered on routine imaging examinations and should not be mistaken for a normal testicle or for a diffusely infiltrated testicle. Occasionally, imaging may be performed to assess for implant integrity. On MRI, the silicone-shell saline-filled implant generally appears hypointense on T1-weighted images and hyperintense on T2-weighted images. Solid silicone elastomer implants resemble a normal testicle (hypointense on T1-weighted images and slightly hyperintense on T2-weighted images), except for chemical shift artifact in the frequency-encoding direction. A silicone gel– filled prosthesis appears dark on both T1and T2-weighted images and may resemble a mass [32]. On CT, a testicular prosthesis appears as an ovoid fluid collection with a hyperdense wall (Fig. 10A). Shell calcification may occur, similar to the calcification commonly seen around breast implants. On ultrasound, a saline-filled implant appears as an ovoid anechoic structure (Fig. 10B). Silicone gel implants have an anechoic center with a well-defined regular contour. Reverberation echoes may be seen just deep to the echogenic interface with surrounding soft tissue [33]. Ultrasound or MRI (or both) may be performed to assess the integrity of the testicular prosthesis. Testicular prostheses are very su-
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perficial and easily imaged with ultrasound, unlike subpectoral breast implants. A stepladder pattern of multiple parallel lines in the implant may represent intracapsular rupture of a silicone gel implant, similar to what is seen with silicone breast implants [33]. MRI is a more accurate method of showing the intracapsular implant rupture, and diagnostic findings of intracapsular rupture include the linguine sign [34]. Complications of testicular implants are similar to those of breast implants, including pain, rupture, fibrous capsule formation, and contracture. Scrotal contraction and migration into the inguinal canal are less common complications [33]. Conclusion Radiologists commonly encounter the postoperative appearance of various implants and cosmetic techniques in the body on routine imaging examinations. Understanding their normal appearance can prevent unnecessary additional imaging. Also, radiologists may be asked to evaluate for radiologic evidence of postoperative complications and prosthesis failure. In this article, the imaging spectrum of the normal appearance and complications of body implants and cosmetic techniques has been discussed, to allow a better understanding of their CT, MRI, and ultrasound appearances. References 1. Benito-Ruiz J, Raigosa JM, Manzano-Surroca M, Salvador L. Male chest enhancement: pectoral implants. Aesthetic Plast Surg 2008; 32:101–104 2. Saour S, Shaaban H, McPhail J, McArthur P. Customised silicone prostheses for the reconstruction of chest wall defects: technique of manufacture and final outcome. J Plast Reconstr Aesthet Surg 2008; 61:1205–1209 3. Benito-Ruiz J. Buttock implants for male chest enhancement. Plast Reconstr Surg 2003; 112:1951 4. Schatz CJ, Ginat DT. Imaging of cosmetic facial implants and grafts. AJNR 2013; 34:1674–1681 5. Johnson PE. Refining silicone implant correction of pectus excavatum through computed tomography. Plast Reconstr Surg 1996; 97:445–449 6. Scaranelo AM, de Fatima Ribeiro Maia M. Sonographic and mammographic findings of breast liquid silicone injection. J Clin Ultrasound 2006; 34:273–277 7. Venkataraman S, Hines N, Slanetz PJ. Challenges in mammography. Part 2. Multimodality review of breast augmentation–imaging findings and complications. AJR 2011; 197:[web]W1031– W1045
8. Vergara R, Amezcua H. Intramuscular gluteal implants: 15 years’ experience. Aesthet Surg J 2003; 23:86–91 9. American Society for Aesthetic Plastic Surgery. 2013 Cosmetic Surgery National Data Bank statistics. www.surgery.org/sites/default/files/Stats2013_3. pdf. Accessed December 9, 2014 10. Mofid MM, Gonzalez R, de la Peña JA, Mendieta CG, Senderoff DM, Jorjani S. Buttock augmentation with silicone implants: a multicenter survey review of 2226 patients. Plast Reconstr Surg 2013; 131:897–901 11. Senderoff DM. Buttock augmentation with solid silicone implants. Aesthet Surg J 2011; 31:320– 327 12. Flores-Lima G, Eppley BL, Dimas JR, Navarro DE. Surgical pocket location for gluteal implants: a systematic review. Aesthetic Plast Surg 2013; 37:240–245 13. Gonzalez R. Gluteal implants: the “XYZ” intramuscular method. Aesthet Surg J 2010; 30:256– 264 14. Darouiche RO. Treatment of infections associated with surgical implants. N Engl J Med 2004; 350:1422–1429 15. Ali A. Contouring of the gluteal region in women: enhancement and augmentation. Ann Plast Surg 2011; 67:209–214 16. Bruner TW, Roberts TL 3rd, Nguyen K. Complications of buttocks augmentation: diagnosis, management, and prevention. Clin Plast Surg 2006; 33:449–466 17. Camuzard O, Dumas P, Foissac R, et al. Severe granulomatous reaction associated with hypercalcemia occurring after silicone soft tissue augmentation of the buttocks: a case report. Aesthetic Plast Surg 2014; 38:95–99 18. Lopiccolo MC, Workman BJ, Chaffins ML, Kerr HA. Silicone granulomas after soft-tissue augmentation of the buttocks: a case report and review of management. Dermatol Surg 2011; 37:720–725 19. Ginat DT, Schatz CJ. Imaging features of midface injectable fillers and associated complications. AJNR 2013; 34:1488–1495 20. Camenisch CC, Tengvar M, Heden P. Macrolane for volume restoration and contouring of the buttocks: magnetic resonance imaging study on localization and degradation. Plast Reconstr Surg 2013; 132:522e–529e 21. Shermak MA. Body contouring. Plast Reconstr Surg 2012; 129:963e–978e 22. Frank SJ, Flusberg M, Friedman S. CT appearance of common cosmetic and reconstructive surgical procedures and their complications. Clin Radiol 2013; 68:e72–e78 23. Stewart KJ, Stewart DA, Coghlan B, Harrison DH, Jones BM, Waterhouse N. Complications of
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Imaging of Cosmetic Plastic Implants 278 consecutive abdominoplasties. J Plast Reconstr Aesthet Surg 2006; 59:1152–1155 24. Darouiche RO, Bella AJ, Boone TB, et al. North American consensus document on infection of penile prostheses. Urology 2013; 82:937–942 25. Moncada I, Jara J, Cabello R, Monzo JI, Hernández C. Radiological assessment of penile prosthesis: the role of magnetic resonance imaging. World J Urol 2004; 22:371–377 26. Cohan RH, Dunnick NR, Carson CC. Radiology of penile prostheses. AJR 1989; 152:925–931 27. Suarez G, Baum N. Ultrasonography in evalua-
tion of mechanical problems of inflatable penile prosthesis. Urology 1987; 30:388–389 28. Brook OR, Ghersin E, Guralnik L, Kaftori JK, Amendola MA, Engel A. Penile prosthesis reservoir: an imaging pitfall. Clin Radiol 2008; 63:343–347 29. Kirkham A. MRI of the penis. Br J Radiol 2012; 85:S86–S93 30. Lowe G, Smith RP, Costabile RA. A catalog of magnetic resonance imaging compatibility of penile prostheses. J Sex Med 2012; 9:1482–1487 31. Turek PJ, Master VA. Safety and effectiveness of a
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new saline filled testicular prosthesis. J Urol 2004; 172:1427–1430 32. Semelka R, Anderson M, Hricak H. Prosthetic testicle: appearance at MR imaging. Radiology 1989; 173:561–562 33. Goyal N, Floyd MS Jr, Agarwal SK, De Bolla AR. Sonographic findings of testicular prosthesis rupture. Clin Radiol 2011; 66:383–384 34. Hage JJ, Taets van Amerongen AH, Van Diest PJ. Rupture of silicone gel filled testicular prosthesis: causes, diagnostic modalities and treatment of a rare event. J Urol 1999; 161:467–471
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Fig. 1—Silicone chest wall implants. A, Axial unenhanced CT image of lower chest shows bilateral silicone pectoral implants in 56-year-old man undergoing workup for detection of urolithiasis. B, Axial contrast-enhanced CT image of chest shows custom-made silicone implant improving chest wall deformity in 28-year-old woman with pectus excavatum. C, Axial IV contrast-enhanced CT image of chest in 39-year-old man with right pectoral implant infection who developed abscess and myositis of right pectoral muscle shows fat stranding in subcutaneous fat; right pectoral muscle has hypoenhancement compared with left. Both implants were removed and abscess was drained.
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Fig. 2—23-year-old man with history of bilateral free silicone injection for pectoral augmentation. A, Axial IV contrast-enhanced CT image of chest shows stranding and enlargement of bilateral pectoral muscles. Silicone is also evident in subcutaneous tissues. B, Mammogram was performed because of palpable lump in right breast. Mediolateral oblique view of right breast shows BB marker at palpable site. Multiple round dense masses represent free injected silicone granulomas (arrow).
Fig. 3—Different surgical pockets for gluteal implant placement are outlined on axial T1-weighted image of pelvis. Orange line delineates borders of right gluteus maximus muscle; light blue dotted line marks right sciatic nerve deep to gluteus maximus muscle; dark blue dotted line illustrates fascia; green line in left buttock shows subfascial pocket, which is superficial; red line shows intramuscular pocket; and yellow line shows submuscular pocket, which is in close contact with sciatic nerve.
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Fig. 4—Complications of gluteal silicone implant. A, Axial IV contrast-enhanced CT image of pelvis in 29-year-old woman with bilateral postoperative seromas 1 week after gluteal implant placement shows rimenhancing collections surrounding both implants, with only minimal fat stranding in subcutaneous fat. B, Axial T1-weighted fat-saturated contrast-enhanced MR image of pelvis in 45-year-old man with infected late seroma 1 year after bilateral gluteal implant placement shows bilateral subfascial gluteal implants in place, with rim-enhancing fluid collection surrounding left implant, as well as fat stranding and enhancement of gluteal subcutaneous fat surrounding left implant. Collection was subsequently drained.
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Fig. 5—Autogenous gluteal augmentation. A, Axial unenhanced CT image of pelvis shows postoperative appearance of autogenous gluteal augmentation and circumferential body lift in 51-year-old woman 1 week after operation. Two fat-density masses in buttocks represent gluteal augmentation, with extensive fat stranding and infiltration, as well as small surrounding fluid collections, which are seromas. Fat stranding in anterior abdominal wall is result of circumferential body lift and liposuction. B, Axial unenhanced CT of pelvis in same patient 8 years later shows two fat-density masses in both buttocks, with round area of calcification in left buttock representing fat necrosis.
Fig. 6—Axial IV contrast-enhanced CT image of pelvis in 22-year-old man who had received gluteal free silicone injection shows extensive stranding and soft-tissue density material and nodules in both buttocks.
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Fig. 7—Abdominoplasty and body lift complication. A, Axial IV contrast-enhanced CT image of abdomen in 45-year-old woman who presented with increasing pain in anterior abdominal wall and fever 2 months after circumferential trunk liposuction and abdominoplasty shows large rim-enhancing fluid collection in anterior abdominal wall, representing infected seroma. Patient underwent incision, drainage, and treatment with doxycycline as sclerosing agent. Note that after abdominoplasty, recti muscles appear approximated or clumped together (asterisks). B, Axial CT image of abdomen after oral and IV contrast administration in 41-year-old woman 1 month after circumferential body lift shows postoperative seroma. Rimenhancing fluid collections (asterisks) are evident in subcutaneous tissue of back, with foci of gas. Clinical findings were suggestive of seroma, rather than abscess, and collections later resolved.
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Fig. 8—CT and MRI appearance of penile prosthesis. A, Axial IV contrast-enhanced CT image of pelvis in 45-year-old man shows inflated penile cylinders placed in corpora cavernosa. Note slight discrepancy in cylinder placement and disuse atrophy of pelvic muscles in this patient with history of poorly controlled diabetes and bilateral lower extremity amputations. B, Coronal unenhanced CT image of pelvis in 61-year-old man shows three-piece inflatable penile implant. Ovoid saline-filled reservoir (asterisk) is evident in pelvis, and dense silicone tubing extends to pump (arrowhead) in scrotum. Note cylinders and associated tubing in corpora cavernosa (arrow). C, Sagittal T2-weighted high-spatial-resolution image of pelvis in 64-year-old man shows normal appearance of three-piece inflatable implant 6 months after prosthesis placement. Arrow denotes deflated cylinders, which may have folds. Normal pump is evident in scrotum (asterisk). D, Coronal T2-weighted high-spatial-resolution image in same patient as C after inflation of cylinders shows symmetric inflation with no evidence of rupture, kink, deformity, or fluid collection.
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Imaging of Cosmetic Plastic Implants
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Fig. 9—Complications of penile prosthesis. A, Axial IV contrast-enhanced CT of pelvis in 83-year-old man with failed penile prosthesis shows severe narrowing, irregularity, and disruption of walls of penile cylinders, which are deflated; reservoir in pelvis was also deflated. These findings likely represent prosthesis failure due to leak. Patient underwent removal of implant and placement of new prosthesis. B, Axial unenhanced CT image of lower abdomen in 46-year-old man with small-bowel injury secondary to reservoir placement shows reservoir in pelvis (asterisk) with surrounding free intraperitoneal gas (arrowhead). Patient presented with fever, abdominal pain, peritoneal signs, and crepitus over site of his reservoir several days after operation. There is extensive mesenteric fat stranding surrounding loops of small bowel adjacent to reservoir. Gas extends to subcutaneous tissue (arrow) on left side of abdominal wall. Patient underwent removal of implant, peritoneal washout, small-bowel resection, and loop ileostomy. C, Axial IV contrast-enhanced CT image of pelvis in 49-year-old man with colonic injury during penile prosthesis reservoir placement shows deflated reservoir (arrow) partially in colon, where tubing and reservoir have migrated. There is dilatation of proximal loops of bowel. D, Sagittal T2-weighted high-spatial-resolution MR image of pelvis in 67-year-old man after inflatable prosthesis placement shows inflated cylinders (arrow) with no evidence of associated hemorrhage or fluid collection. Patient inflated prosthesis within few days after placement and was not able to deflate it and presented with severe pain. MRI of pelvis was performed mainly to differentiate hemorrhage surrounding cylinders from inflated cylinders. Implant was manually deflated in operating room, and adhesions were found surrounding scrotal pump (asterisk). Release of adhesions resulted in proper implant function. E, Coronal T2-weighted high-spatial-resolution MR image of penis and scrotum in 71-year-old man with penile implant infection 2 months after implant placement shows small amount of fluid (arrows) in both hemiscrotums, surrounding pump (asterisk) and cylinders. Patient was not able to inflate cylinders during MRI owing to severity of pain. Patient underwent implant removal, washout, and placement of new three-piece implant, resulting in resolution of symptoms.
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Fig. 10—Testicular prosthesis in 25-year-old man with history of seminoma and right orchiectomy. A, Coronal unenhanced CT image of pelvis shows saline-filled testicular prosthesis (asterisk) with dense rim of silicone. Note normal testicle on left. B, Sagittal ultrasound image of right scrotum shows ovoid anechoic implant with posterior acoustic enhancement.
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