Management of Intracapsular Breast Implant Rupture with Multiple Sonographic Signs
Given the presence of both stepladder sign and subcapsular lines sign (two distinct signs of rupture) on ultrasound, these findings can be acted upon directly, but MRI confirmation is recommended before proceeding to surgical consultation for optimal management planning. 1
Immediate Next Step: MRI Confirmation
MRI without contrast should be obtained to confirm the intracapsular rupture before finalizing surgical plans, as it remains the gold standard with 87% sensitivity and 89.9% specificity for detecting implant rupture. 1, 2
The ACR guidelines specifically state that when more than 2 signs of rupture are detected on ultrasound (as in this case with both stepladder and subcapsular lines signs), the findings can be acted upon; however, MRI remains valuable for surgical planning and confirming the extent of rupture. 1
MRI will identify whether this is a complete intracapsular rupture (showing the characteristic "linguini" or "wavy-line" sign) or incomplete rupture (showing "keyhole," "teardrop," or "hang noose" signs), which impacts surgical decision-making. 1, 2
Critical Caveat About Ultrasound Findings
Be aware that false-positive ultrasound diagnoses of implant rupture can occur due to reverberation artifacts, complex radial folds, silicone impurities, fluid retention within the capsule, or hematogenous serous effusion that can mimic rupture signs. 1, 3
Recent evidence shows that while ultrasound can achieve 94.7% diagnostic accuracy when performed by experts, the presence of artifacts means MRI confirmation prevents unnecessary surgery in cases where the implant is actually intact. 1, 3
Surgical Consultation and Management
Referral to plastic surgery should occur after MRI confirmation, as intracapsular ruptures (where the fibrous capsule remains intact) are typically asymptomatic and pose minimal immediate health risk. 4
There is no consensus requiring urgent surgery in asymptomatic patients with intracapsular rupture alone, unlike extracapsular rupture which requires more urgent intervention within 2-4 weeks. 4
The patient should be counseled that intracapsular rupture is often clinically silent and that the decision for explantation versus observation can be made electively after MRI confirmation. 2, 4
Surgical Options After Confirmation
Explantation with or without replacement is the definitive management option once intracapsular rupture is confirmed on MRI. 5, 6
If the patient chooses observation rather than surgery, ongoing monitoring every 2-3 years with MRI or ultrasound is recommended by the FDA to detect progression to extracapsular rupture. 4, 7
Complete removal of all silicone and capsular tissue should be the goal if surgery is pursued, though patients should understand that complete removal may not always be possible. 4
Ongoing Surveillance
If a new implant is placed after explantation, the FDA recommends continued monitoring with MRI or ultrasound to detect future complications such as silicone migration or recurrent rupture. 2
The BI-RADS-2 (benign) classification addresses cancer risk only and does not change the management approach for the confirmed implant rupture. 7
Important Clinical Pearls
Physical examination is unreliable for detecting implant rupture, making imaging crucial for diagnosis and management decisions. 2, 4, 7
The absence of symptoms does not reduce the need for appropriate imaging workup and surgical evaluation when rupture is suspected on ultrasound. 4
Intracapsular rupture may complicate future breast imaging and cancer detection if left in place, which should factor into shared decision-making with the patient. 4