What is the approach to managing a breast implant emergency in the emergency department?

Management of Breast Implant Emergencies in the Emergency Department

The initial approach to breast implant emergencies should follow a systematic algorithm based on implant type, patient age, and presenting symptoms, with ultrasound being the first-line imaging modality for most acute presentations.

Initial Assessment

Key Clinical Presentations

• Implant rupture:
  • Saline: Usually clinically evident with change in breast contour as saline is resorbed 1
  • Silicone: May be asymptomatic (intracapsular) or present with palpable masses/contour changes (extracapsular) 1, 2
• Infection: Erythema, pain, swelling, warmth, fever
• Seroma: Sudden breast enlargement, asymmetry, discomfort
• Hematoma: Acute pain, swelling, ecchymosis
• Exposure/extrusion: Visible implant through compromised skin

Diagnostic Imaging Algorithm

For Suspected Saline Implant Rupture

• Age <30 years: Ultrasound is first-line imaging 1
• Age 30-39 years: Either ultrasound or mammography/DBT 1
• Age ≥40 years: Mammography/DBT is first-line, with ultrasound for problem-solving 1

For Suspected Silicone Implant Complications

• All age groups: MRI without contrast is the most accurate modality (sensitivity 87-96%, specificity 89-97%) 1, 2
• When MRI unavailable: Ultrasound can detect extracapsular rupture but has variable accuracy for intracapsular rupture 2

For Suspected Breast Implant-Associated Anaplastic Large Cell Lymphoma (BIA-ALCL)

• All ages: Ultrasound is first-line imaging regardless of implant type 1
• If fluid collection present: Ultrasound-guided aspiration for cytology 1

Management of Specific Emergencies

Implant Rupture

1. Saline implant rupture:

   • Usually requires only clinical diagnosis
   • Surgical consultation for eventual replacement (non-emergent)
   • No additional imaging if clinically evident 1

2. Silicone implant rupture:

   • Intracapsular: Document with appropriate imaging; surgical consultation
   • Extracapsular: Urgent surgical consultation for explantation and capsulectomy 2
   • Complete removal of all silicone material is crucial to prevent migration and immune stimulation 2

Infection

1. Mild infection:

   • Immediate empirical oral antibiotics
   • Surgical consultation within 24 hours
   • 90-95% salvage rate if treated early 3, 4

2. Severe infection:

   • Immediate IV antibiotics (broad-spectrum)
   • Urgent surgical consultation for possible drainage, debridement
   • Lower salvage rate (approximately 30%) 3
   • Consider hospital admission

Seroma/Hematoma

1. Acute hematoma:

   • Urgent surgical consultation for evacuation if large or expanding
   • Small stable hematomas may be observed with close follow-up

2. Late seroma:

   • Ultrasound-guided aspiration with fluid sent for cytology to rule out BIA-ALCL 1
   • Culture fluid to rule out infection

Implant Exposure/Extrusion

1. Without infection:

   • Clean wound, apply sterile dressing
   • Immediate surgical consultation
   • Potential for salvage with appropriate surgical intervention (90% success rate) 3

2. With infection:

   • Immediate IV antibiotics
   • Urgent surgical consultation for debridement and possible explantation
   • Lower salvage rate, especially with severe infection 3

Critical Pitfalls to Avoid

1. Delayed diagnosis of BIA-ALCL: Any unexplained seroma >1 year after implantation requires aspiration and cytology 1

2. Misdiagnosis of normal implant folds as rupture: Clinical examination alone is unreliable; appropriate imaging is essential 2

3. Inadequate treatment of infection: Early aggressive intervention significantly improves implant salvage rates 3, 4

4. Failure to recognize silicone migration: Silicone can migrate to regional lymph nodes, pectoralis muscle, and chest wall 2

5. Overlooking implant-related systemic symptoms: Consider breast implant illness in patients with unexplained systemic symptoms 2

Disposition

• Outpatient management: Mild infections responsive to oral antibiotics, small stable seromas, uncomplicated saline implant rupture
• Surgical referral within 24-48 hours: Most implant complications requiring non-emergent intervention
• Admission: Severe infection, large or expanding hematoma, systemic symptoms, implant exposure with infection

By following this systematic approach to breast implant emergencies in the ED, clinicians can ensure appropriate diagnosis, management, and disposition of these patients while avoiding common pitfalls.