What are the next steps for a patient with an intracapsular rupture of a right breast silicone implant (implant with a tear inside the capsule surrounding the implant) and suspected herniation, with no evidence of malignancy on initial imaging without intravenous (IV) contrast?

Management of Right Breast Intracapsular Silicone Implant Rupture with Suspected Herniation

The patient requires referral to plastic surgery within 2-4 weeks for evaluation and surgical planning, as the suspected herniation represents capsular weakening that increases the urgency beyond typical asymptomatic intracapsular rupture. 1

Understanding the Current Findings

The imaging report describes an intracapsular rupture (implant shell has failed but the fibrous capsule remains intact) with suspected superior and medial herniation of the implant. 2 This herniation finding is critical because:

• Herniations represent areas of weakening of the fibrous capsule and potential weak points of the elastomer shell, distinguishing this from a simple intracapsular rupture. 2
• While extracapsular rupture is considered "less likely," the presence of herniation suggests the capsule is compromised and at higher risk for progression to extracapsular rupture. 2
• Frank bulges or herniations represent areas of weakening of the fibrous capsule and potential weak points, making this a more urgent situation than typical asymptomatic intracapsular rupture. 2

Immediate Next Steps

1. Confirm Diagnosis with MRI Without Contrast

MRI without contrast is the gold-standard imaging study for evaluation of silicone implant rupture and should be obtained to definitively characterize the rupture and assess for extracapsular extension. 2

• MRI has sensitivity of 87% and specificity of 89.9% for detecting implant rupture, far superior to the non-contrast study already performed. 2
• The current study is explicitly "nondiagnostic for evaluation of malignancy without IV contrast," necessitating additional imaging. 2
• MRI can identify the "linguini" or "wavy-line" sign (most specific for complete intracapsular rupture) or "inverted-loop," "keyhole," "teardrop," or "hang noose" signs for incomplete rupture. 2, 3
• Critically, MRI will definitively determine whether extracapsular rupture is present, which would significantly change management urgency. 2

2. Plastic Surgery Referral

Refer to plastic surgery within 2-4 weeks for evaluation and surgical planning. 1

The rationale for this timeframe includes:

• The suspected herniation increases urgency beyond typical asymptomatic intracapsular rupture, where there is no consensus requiring surgery. 1
• If extracapsular rupture is confirmed, silicone can migrate to regional lymph nodes and distant sites, presenting as palpable masses that may mimic breast cancer. 1
• Complete removal of extracapsular silicone may not be possible if present, but explantation prevents further migration. 1

Surgical Considerations

Patient Counseling Points

• Intracapsular ruptures where the fibrous capsule remains intact are typically asymptomatic and pose minimal immediate health risk. 1
• However, the suspected herniation indicates capsular compromise, placing this case in a higher-risk category. 2
• Physical examination is unreliable for detecting rupture, so the absence of symptoms does not reduce the need for evaluation when imaging suggests rupture. 1
• If extracapsular rupture is confirmed, the patient should understand that complete silicone removal may not be achievable, but explantation prevents further migration. 1

Post-Surgical Monitoring

• If new implants are placed, the FDA recommends ongoing monitoring with MRI or ultrasound every 2-3 years to detect future complications. 1, 3
• Leaving a ruptured implant in place may complicate future breast imaging and cancer detection. 1

Malignancy Evaluation

Since the study was nondiagnostic for malignancy:

• MRI with contrast would be needed if there are clinical concerns for malignancy or if the patient has other risk factors requiring cancer screening. 2
• However, MRI without and with contrast is not indicated specifically for silicone implant evaluation alone. 2
• The focus should remain on implant integrity assessment with non-contrast MRI, with contrast added only if malignancy evaluation is independently indicated. 2

Common Pitfalls to Avoid

• Do not delay referral assuming this is a "simple" intracapsular rupture – the herniation finding suggests capsular compromise requiring evaluation. 2, 1
• Do not rely on ultrasound alone – while US can show "step-ladder" appearance of collapsed implant shell, it has poor sensitivity (30%) and accuracy (72%) for intracapsular rupture. 2
• Do not assume absence of symptoms means no action is needed – the herniation finding changes the risk profile. 1
• Do not order MRI with contrast for implant evaluation – this adds no value for assessing implant integrity. 2