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Signs in Imaging

Amjad Safvi, MS, MD

Linguine Sign1
APPEARANCE
The linguine sign is seen at magnetic resonance (MR) imaging
of silicone breast implants by using T2-weighted spin-echo or
fast spin-echo methods with or without water suppression. The
breast implant contains multiple curvilinear low-signal-intensity lines within the high-signal-intensity silicone gel. The
lines are usually scattered diffusely and appear as long strands
of decreased signal intensity curved on top of each other.

EXPLANATION
The linguine sign indicates intracapsular rupture of the silicone breast implant (1). The breast implant is made of a Silastic
elastomeric shell containing silicone. The elastomeric shell
breaks, which releases the silicone inside. A fibrous capsule
(scar tissue) forms around the breast implant after it is placed
into the breast. The fibrous capsule usually contains the silicone as the shell collapses. The serpentine lines represent layers of collapsed elastomeric shell floating in the silicone gel
within the fibrous capsule.
The Silastic elastomeric shell appears as low-signal-intensity
lines, and the silicone gel appears as high signal intensity on
T2-weighted images. Medical-grade silicone is composed of
dimethyl siloxane, a silicon molecule with two methyl groups
linked to each other by oxygen molecules in a polymer chain.
The MR signal intensity is derived from the protons of the
methyl groups. The Silastic elastomeric shell is also composed
of the same polymer but has increased cross-linkage of the
methyl groups, which results in an elastic solid. This linked
polymer produces a lower MR imaging signal intensity than
the unlinked silicone gel polymer (2).

Index terms:
Breast, MR, 00.121411
Breast, prostheses, 00.4543, 00.91
Signs in Imaging
Silicone, 00.4543
Radiology 2000; 216:838 839

Sagittal T2-weighted short-T1 inversion-recovery MR image (3,000/60 [repetition time msec/


echo time msec]) obtained with fat suppression shows intracapsular rupture of a silicone
breast implant, as demonstrated by the linguine sign (arrow).

DISCUSSION
There are several types of breast implants. Most are singlelumen silicone prostheses containing silicone gel within an
outer elastomeric silicone shell. Implants can also contain
saline or be made of a combination of saline and silicone in
different encapsulated shells. The surface can be smooth or
textured; the latter is thought to decrease the formation of
capsular contractures, which is a fairly common complication.
Gel bleeding indicates microscopic leakage of silicone
through the shell. There almost always is some degree of leakage of silicone gel from the implant. In intracapsular implant

From the Department of Radiology, Northwestern Memorial Hospital, Chicago, Ill. Received March 3, 1998; revision requested April 29;
final revision received April 26, 1999; accepted August 30. Address
correspondence to the author, 296 Hawkeye Court, Iowa City, IA
52242.
RSNA, 2000

838

A trainee (resident or fellow) wishing to submit a manuscript


for Signs in Imaging should first write to the Editor for approval
of the sign to be prepared, to avoid duplicate preparation of the
same sign.

rupture, the fibrous capsule contains the silicone. In extracapsular rupture, the silicone breaks free from the ruptured fibrous
capsule and the ruptured implant and leaks into the breast
parenchyma.
The linguine sign (Figure) indicates intracapsular rupture of
the breast implant. This MR imaging sign is the most sensitive
among all the signs of intracapsular rupture from other imaging modalities, with a sensitivity of 96% and a specificity of
94% (3). The wavy lines on MR images represent the collapsed
shell floating in the silicone. Although the linguine sign is
fairly easy to detect, the signs of early intracapsular rupture (4)
(tear drop sign, keyhole sign, subcapsular line sign) were more
common than the linguine sign in a study of 86 breast implants (5).
The Silastic elastomeric shell by design is not wrapped tautly
around the silicone gel. There is room left for the implant to be
molded and be pliable. There is a small amount of natural
infolding of the implant shell seen on MR images obtained in
women with intact, normal implants. This may produce curvilinear lines similar to the linguine sign. Lines longer than 3

Volume 216

Number 3

cm seen on multiple consecutive images indicate a ruptured


implant (5). There usually is some undulation of these lines,
which indicates a free-floating elastomeric shell. Intracapsular
rupture of breast implants can be easily and confidently detected with the presence of the linguine sign.

References
1. Gorczyca D, Sinha S, Ahn C, et al. Silicone breast implants in vivo:
MR Imaging. Radiology 1992; 185:407 410.
2. Gorczyca D. MR imaging of breast implants. Magn Reson Imaging
Clin N Am 1994; 2:659 672.
3. Samuels JB, Rohrich R, Weatherall P, et al. Radiographic diagnosis
of breast implant rupture: current status and comparison of techniques. Plast Reconstr Surg 1995; 96:865 877.
4. Soo MS, Kornguth P, Walsh R, et al. Complex radial folds versus
subtle signs of intracapsular rupture of breast implants: MR findings with surgical correlation. AJR Am J Roentgenol 1996; 166:
14211427.
5. Soo MS, Kornguth PJ, Walsh R, et al. Intracapsular implant rupture:
MR finding of incomplete shell collapse. J Magn Reson Imaging
1997; 7:724 730.

Linguine Sign

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