Ms. Tzur is a 70-year-old female with bilateral breast implants. Patient reports a nontender palpable mass in the right upper outer breast for the past 3 weeks. Upon physical exam at the patient's area of concern, a vague palpable mass is identified in the right upper outer breast.A targeted right breast ultrasound was performed for the palpable area of concern. In the right breast 10:00 location, approximately 4 cm from the nipple, there are three focal areas of increased echogenicity identified with blurring of the silicone implant contour. Sonographic findings are compatible with extracapsular rupture.
Sonographic findings compatible with extracapsular rupture of right silicone implant. A breast MRI can be performed for additional confirmation if clinically warranted. All results and recommendations were discussed with the patient. Patient is to follow-up with Donna Christian later today for further evaluation.BIRADS: 2 - Benign finding.RECOMMENDATION: B - Surgical Consultation