What is the emergency department management for a patient with a ruptured saline breast implant?

Emergency Department Management of Ruptured Saline Breast Implant

Ruptured saline breast implants require minimal emergency intervention as they pose no significant health risks, and clinical reassurance with referral to plastic surgery for definitive management is the appropriate emergency department approach. 1

Initial Assessment

• Clinical Presentation: Saline implant rupture is typically clinically evident with:

  • Noticeable breast asymmetry
  • Decreased breast size on the affected side
  • Change in breast shape occurring over days as saline is resorbed by the body 1

• Physical Examination:

  • Assess for asymmetry between breasts
  • Look for visible collapsed implant shell
  • Evaluate for signs of infection (erythema, warmth, tenderness)
  • Check for any associated trauma to surrounding tissues

Diagnostic Imaging

Imaging is typically not necessary in the emergency department for obvious saline implant rupture, but may be helpful in equivocal cases:

• For patients <30 years of age:

  • Ultrasound is the initial examination of choice 1
  • The collapsed implant shell is visible on ultrasound

• For patients 30-39 years of age:

  • Either ultrasound or diagnostic mammography/DBT may be used 1
  • Both can visualize the collapsed implant shell

• For patients ≥40 years of age:

  • Diagnostic mammography/DBT is the first-line examination if imaging is required 1
  • Ultrasound may be used if mammographic findings are equivocal or the patient cannot undergo mammography

• MRI has no role in the evaluation of saline implant rupture 1

Management

1. Patient Reassurance:

   • Explain that saline is sterile salt water that is safely absorbed by the body without health risks 2
   • Clarify that no emergent intervention is needed

2. Pain Management:

   • Mild analgesics if needed for discomfort
   • Cold compresses may help with any associated swelling

3. Referral:

   • Arrange outpatient plastic surgery consultation for definitive management
   • Typical options include observation or explantation with possible replacement 2

4. Discharge Instructions:

   • No emergency surgical intervention is required
   • Monitor for signs of infection (increasing pain, redness, warmth, fever)
   • Return if symptoms worsen before plastic surgery follow-up

Important Considerations

• Cause of Rupture: Most common causes include:

  • Instrument damage during placement
  • Implant folding (especially with underfilled implants) 3
  • Trauma to the chest
  • Normal implant aging (risk increases after 6-8 years) 4

• Complications: Saline implant rupture has minimal complications compared to silicone:

  • No risk of silicone migration to tissues
  • No associated systemic health risks 2
  • Main issue is cosmetic deformity

• Pitfalls to Avoid:

  • Don't mistake saline implant rupture for silicone implant rupture (management differs significantly)
  • Don't order unnecessary MRI imaging for saline implant evaluation 1
  • Don't delay plastic surgery referral, as longer duration between rupture and replacement may complicate future reconstruction

• Implant Identification: If uncertain which type of implant the patient has:

  • Ultrasound can determine implant type by examining the margin
  • Silicone implants show a "step-off" appearance not seen in saline implants 1

Remember that while saline implant rupture requires definitive management, it is not an emergency requiring immediate surgical intervention in the ED setting.