Implant materials are radiodense and, in most cases, they appear as prominent objects under screen film or mammoxerographic projection. Screen film studies are not as effective as xeromammographic investigation for detection of prostheses and tissue anomalies in the presence of implants. Currently popular screen film X-ray units have other deficiencies; the breast-retaining fixtures often forbid viewing of the retroprosthetic space.

Tissue anomalies can be partly eclipsed by the prostheses and their artifacts. A strongly radiodense fibrous capsule further complicates the interpretation and generally demands more views to characterize a patient. This increases the radiation exposure. Conventional criteria of malignancy such as clustered micro-calcifications are much less perceptible in fields containing prostheses and their debris.

Poor detail of breast tissue and low contrast problems in many currently used screen film mammographic units, in combination with imperfect techniques, militate strongly against the routine use of radiography for cancer detection and prostheses problems in implant users. The discomfort, the palpable irregularities and the unnatural feel of a mature, augmented breast with capsule can further motivate the patient as well as many clinicians to avoid radiography and to discount visualized abnormalities suggestive of solid tumors.

Radiographically detectable tumors and prostheses-related problems precede gross symptoms. Radiographic studies can therefore provide valuable diagnostic information even with respect to small tumors. However, such studies are often discouraged by the plastic surgery community. In addition, prostheses greatly complicate the evaluation and the accuracy of diagnostic procedures involving small tumors.

Prosthetic systems habitually calcify in the late phase and deposit large amounts of radio-opaque calcific debris. This material is unlike occasionally encountered dystrophic calcifications and can mimic micro-calcifications around tumors. This is particularly true when patients undergo incomplete removal of calcified devices. For these reasons, the value of radiography in tumor detection is greatly diminished to prostheses users and the evaluation of such mammographic information requires skill and experience which is not universally encountered within the clinical community. Because of difficulties with false positives and frequent false negatives, radiographically-detectable tumors may be neglected or passed off as artifacts. Even saline-filled implants are radio-opaque and greatly complicate mammography.

The detection of malignant tumors is dependent on dedicated, well equipped breast radiology centers. Most clinicians skilled in that art are also able to assess the condition of the medical implants. The presence of gel-filled prostheses modifies the radiographic presentation of breasts but does not exclude successful cancer screening by manual or radiographic techniques. Some of these techniques require strong compression and deformation of the breast which can be extremely painful to patients with old implants.

The compression procedure can impart severe damage to the tissue and cause rupture of compromised prostheses. The compression of the breast can also spread extravasated prosthetic filling material far from the prosthetic site. Whereas strong compression of the breast is necessary to visualize tumors, such procedures are not necessary for the evaluation of the prostheses or their capsules. Typically, the Eklund technique can be used to visualize the anterior part of the breast which has been augmented with a prosthesis. However, this technique is not suitable for patients with older implants, implants with fixation patches and devices which are suspected of rupture, in particular when there is strong contracture or mineralization. Users with extensively degraded prostheses such as the Meme MEs and other devices with thin frangible shells are particularly subject to extrusion of free gel in areas remote from the original implantation site.

Implants can obscure tumors mechanically. Most implants are comparatively large and the breasts that contain them require multiple views and unusual mammographic angles in order to visualize the surrounding tissue. For this reason, dominant or clinically suspicious breast masses generally need to be investigated through biopsy or other recognized cancer diagnostic methods to establish their risk. This is not consistently done when implants are in situ.

Diffuse or amorphous (non-calcific) densities in tissue surrounding prostheses are commonplace and appear related to the penetration of invasive prosthetic materials and their degradation products into the breast; the process often causes secondary fibrosis which may further densify the area of interest and further complicates the interpretation of mammograms that show discrete densities.

Significant amounts of impure silicone oils from the filling gel leak out of superficially "intact" prostheses. Quantities accumulated in periprosthetic tissue vary according to time of use, device type and time of exposure (dwell time). Prostheses with fixation patches cause deep and dense fibrosis as well as severe calcification. These areas are well suited to hide tumors and no currently used technique can provide good visualization of the posterior side of the devices near the chest wall.

Percutaneous needle biopsies not aided by precise stereotactic fluoroscopy cannot be safely performed on augmented breasts in proximity to a prosthesis. This is a major deterrent to the use of the technique. Prostheses must be removed prior to such studies. Implants disturbed by biopsies, tissue sampling procedures performed incidental to resection, irradiation of tumor residuals or open capsulotomy for contracture cannot be returned to the surgical site or reused without risking early rupture and/or serious infective complications. Tissue surrounding prostheses cannot be safely salvaged for reconstruction of a resected breast. Such tissue have elevated levels of contamination and may heal to form closed pockets, seromas or hematomas.

Compressive manipulation of the breast for mammography, manual appraisal of tumors or for cosmetic capsule release (closed capsulotomy), entails significant risks of shell rupture with extravasation and dissemination of aggressive filling material. The risk of such accidents increase with the age of the device. Such procedures cannot be safely performed on most devices after 2 years in situ or on any patient exhibiting radiographically visible periprosthetic breast calcification.

In summary, the successful detection of tumors and tissue anomalies in tissue near implants depends on the type of machine available, the number of viewing angles, the quality and contrast of each view and the projection angles chosen for the mammograms. Antecedent records are generally essential and ideally should be of the same type.

In the light of present knowledge, the radiographic detection of a density with stellated microcalcification and peripheral inflammation to discrete radiodense zones in the vicinity of a prosthesis, has the same oncologic significance as in a natural breast; this type of presentation is not subject to false positives and the patient is deemed to require prompt medical and surgical attention. Conversely, the apparent absence of radiographically-evident tissue anomalies is subject to the elevated probability of false negatives; it does not exclude the possibility of small, active tumors hidden in the periprosthetic infrastructure.