Continuing Education Activity

Breast augmentation is a surgical procedure designed to enhance the size of the patient's breasts, using implants (saline or silicone) or fat transfer. The implants are placed in a retroglandular or retropectoral fashion within the breast. One possible complication after surgical augmentation using saline or silicone implants is implant rupture. This activity explains the risk factors, evaluation, and management of breast implant rupture and highlights the importance of the interprofessional team in enhancing care for affected patients.

Objectives:

• Describe the clinical presentation of patients with breast implant rupture.

• Outline the evaluation of patients with breast implant rupture.

• Explain the treatment strategies for breast implant rupture.

• Employ interprofessional team strategies for improving care coordination and communication to advance the evaluation and management of breast implant rupture and optimize outcomes.

Introduction

Breast augmentation is a surgical procedure where fat transfer or breast implants (saline or silicone) are used within the native breast to increase size and projection. The implants are placed in a retroglandular or retropectoral position. Breast augmentation is performed for various reasons, including cosmetic augmentation, congenital malformations, or reconstruction after mastectomy. Approximately 3.5 million people in the United States have breast implants, making it one of the most commonly performed cosmetic surgical procedures. One possible complication of this procedure is implant rupture, which can occur in different ways. There are many different varieties of saline and silicone implants, and any can potentially degrade, leading to rupture. When evaluating a potential implant rupture, important determinations to make include the makeup of the implant (saline implant or silicone implant), and the length of time the implant has been in place. 

When an implant is placed, the body creates a scar around the implant, a fibrous capsule. This is a normal reaction to the foreign implant. An implant rupture contained within the fibrous capsule is referred to as an intracapsular rupture, while the extravasation of silicone outside of the fibrous capsule is called an extracapsular rupture. Saline implant rupture results in the extravasation of a simple isotonic saline solution that is harmless and will be reabsorbed by the body over time. Silicone implant rupture, however, can lead to further complications, though no actual health risks have been discovered in studies performed. An extracapsular rupture results in silicone gel extravasating into the surrounding tissues, often in an infiltrative pattern that can lead to significant local tissue reaction and scar formation.

One important point is that there cannot be an extracapsular rupture without an intracapsular rupture; in other words, if the implant contents have escaped through the fibrous capsule, they are, by definition, present in the intracapsular space as well. There is a distinction between older iterations of silicone prostheses and more cohesive, new-generation silicone implants. Apart from some exceptional circumstances, cohesive silicone will not spread to surrounding tissue; however, the silicone present in older generations of implants can be subject to wide dissemination and, in rare cases, has migrated as far as the inguinal area.[1][2][3]

Etiology

The most common causes of implant rupture are secondary to the normal aging of the implant, as all prostheses have a recommended lifespan and are prone to rupture eventually once this is exceeded. Literature and personal experience allow physicians to estimate this timeframe, which can range from 12 to 35 years.[4] All ruptures occurring within 20 years are premature in the case of modern implants. These early ruptures are related to various causes which include incompetent valves, manufacturing defects, and underfilling of the implant, which leads to folds in the implant capsule, thus provoking premature weaknesses in the wall. Trauma can also lead to implant rupture. Most blunt trauma does not cause a prosthesis rupture, with the possible exception of high-velocity, direct, blunt trauma to the breast (eg, impact on a steering wheel in a motor vehicle accident). Nonpenetrating traumas were encountered in closed capsulotomies of old silicone prostheses, but these are seen less frequently today as many of this generation of implants have been replaced, and more modern implant construction was designed to prevent this complication.[5][6][7][8]

Epidemiology

The incidence of implant rupture increases with the age of the implant. Prosthesis wall thickness does not play any determinant role in ruptures, as companies offer inflatable prostheses of varying wall thicknesses, and all have a similar rupture rate. Overfilling is rarely responsible for ruptures, though it is essential to comply with filling guidelines for any individual implant.

Pathophysiology

In saline prostheses, apart from the diminution in breast volume, few other symptoms can be identified. If exploration happens at a very early stage after deflation, the surgeon will notice a certain amount of clear fluid (saline from the implant) still present within the capsular pocket. If surgery is performed long after deflation, water in the capsular pocket will have diminished, and only the deflated implant will likely be encountered within the capsule. In the case of old silicone prostheses ruptures, silicone will be free inside the capsular pocket, and apart from the inflammatory process in the thickened capsule, some free and encapsulated silicone (granuloma) can be found in the surrounding tissue.

History and Physical

For saline prostheses, the most common sign associated with implant rupture is the evidence of volume diminution, which can be acute or gradual. There is rarely pain with a saline implant rupture outside of the infrequent post-traumatic ruptures. In silicone prostheses, some degree of chest wall pain may be present as the granulomatous inflammatory reaction takes place. A saline implant rupture is easy to detect on physical examination. It is often referred to as a deflated breast. It decreases in size over the course of a few days. If the saline implant deflates within a few days of insertion, is it suggestive of iatrogenic damage or an improperly closed valve.

For a mature implant, a recent history of trauma could be the cause of the rupture; but in the absence of this, manufacturing defects may be responsible, or late-stage implant failure may indicate the end of the lifespan of the implant. Silicone implant rupture is difficult to detect on physical examination, with a majority of cases being intracapsular; further evaluation with imaging is often required. Extracapsular silicone implant ruptures can sometimes produce a palpable mass or irregularity of the breast as inflammation and granulomatous tissue form; alternately, they may present with vague pain or tenderness symptoms or may be completely asymptomatic. Lymphoma has also been reported in association with a certain subset of breast implants, so the astute surgeon must always remember to query the patient regarding axillary or local masses and systemic symptoms that could herald lymphoma.

Pertinent questions for the suspected implant rupture are therefore:

• When was the implant placed?
• What type of implant was placed (if known)?
• Onset/duration of any symptoms
• Fevers/chills, or B-symptoms

Pertinent physical examination findings include:

• Breast shape and symmetry
• New breast masses
• Associated lymphadenopathy in the axillae or elsewhere
• The texture of the breast implant in question versus the contralateral breast implant
• Skin changes in the affected breast versus the contralateral breast
• Nipple discharge

Evaluation

A saline implant rupture often requires no radiographic evaluation. As described above, a simple clinical evaluation demonstrating volume loss is sufficient. If mammography imaging is obtained, then the implant will often demonstrate a wrinkled appearance. An intact implant will demonstrate a simple anechoic interior on ultrasound, while a rupture will demonstrate folds or wrinkles in the implant capsule. Magnetic resonance imaging (MRI) will show a saline implant following fluid signal on all sequences.[9][10][11]

An intracapsular silicone implant rupture is very difficult to see on mammography. A bulging of the implant contour can suggest an intracapsular rupture. Ultrasound lacks sufficient sensitivity to show intracapsular ruptures, as the silicone is relatively hypoechoic and produces significant artifacts on imaging. The most reliable finding is called a stepladder sign, in which multiple linear echoes are noted in the implant. MRI is the most sensitive at detecting silicone implant rupture. The demonstration of silicone on both sides of a radial fold is known as the keyhole, noose, or teardrop sign (all referring to the same finding). The finding of multiple folds of the implant shell layering upon itself is referred to as the linguine sign and is highly indicative of an intracapsular rupture. This should not be confused with the normal radial folds/creases of an implant, which are often straight, thick, short, and extend to the periphery of the shell. Computed tomography (CT) imaging will also demonstrate the characteristic linguine sign, but with an overall low sensitivity and high radiation dose is not used to evaluate implant rupture. It is often incidentally seen on CT.

Extracapsular rupture can often be seen with mammography and ultrasound, showing the extravasated silicone in the surrounding tissues or even axillary lymph nodes. The snowstorm sign is a sonographic finding of silicone gel droplets mixed with breast tissue, showing a heterogeneous echogenic appearance resulting from the dispersion of the ultrasound beam. MRI is still the modality of choice to determine the extent of the extravasation. The silicone will have a low signal on T1 and a high signal on T2 fat-suppressed images. Computed tomography is not used to evaluate extracapsular rupture because the silicone and the surrounding soft tissues demonstrate a similar radiodensity

Treatment / Management

The empty shell of a ruptured saline implant should be removed. A ruptured silicone implant, whether intracapsular or extracapsular, should be removed because of the possible interaction with surrounding tissue and possible spread to local lymph nodes. Replacement with a more modern implant, whether silicone or saline, should be offered. Asymptomatic patients may be reluctant to undergo this procedure, but the overall long-term safety should be emphasized, and the risk of malignancy discussed. If an intracapsular rupture occurs, then a capsulectomy can be performed. If all silicone has been cleaned (if the rupture was very recent, this is possible), the surgeon may not remove the fibrous capsule. If there is a doubt about silicone persistence, the surgeon should attempt to remove the entire fibrous capsule that has been infiltrated by silicone. A capsulectomy will be necessary in case of calcification. If the rupture is extracapsular, then it is possible that the patient will need several surgeries to retrieve all of the extravasated silicone gel, with a delayed replacement of the implant to restore normal breast contour.

Differential Diagnosis

The differential diagnosis for breast implant ruptures include the following:

• Damage by a surgical instrument

• Needle insertion during a biopsy

• Normal aging of implant

• Trauma caused by a car accident

Pearls and Other Issues

Breast implants have an expiration date and a lifespan and may need to be replaced to avoid complications such as implant rupture. The rate of implant rupture can be directly related to the age of the implant (in the absence of obvious, severe trauma). With over 3.5 million individuals with breast implants in the United States, it is imperative for medical professionals to understand the common presentation, diagnostic exams, common imaging findings, and management.

Enhancing Healthcare Team Outcomes

Breast implants are not permanent and have a definitive lifespan that varies from 12 to 35 years. With advancing age, they have the potential to rupture, and hence, all healthcare professionals should be familiar with the workup. These patients are best managed by the plastic surgeon. Once an implant has ruptured, it needs to be surgically removed. In some cases, several procedures are required to completely remove the implant and the adjacent fibrosis. [12]