What imaging study should be done for a patient with a dehisced wound on the breast, status post debridement, with an exposed breast implant and no leukocytosis (white blood cell count)?

Imaging for Exposed Breast Implant After Wound Dehiscence

Yes, you should obtain imaging, and ultrasound is the most appropriate initial study for this clinical scenario to evaluate for fluid collections, assess the implant integrity, and guide immediate surgical management.

Primary Imaging Recommendation

Ultrasound is the imaging modality of choice for your patient with an exposed breast implant following wound dehiscence. 1 Here's why this is the optimal approach:

• Ultrasound can rapidly identify peri-implant fluid collections (seroma, hematoma, or abscess) that may be contributing to wound breakdown and implant exposure 1
• US detects extracapsular silicone rupture with the classic "snowstorm" pattern if the implant has been compromised during debridement or from the wound complication 1
• US is immediately available and can be performed at the bedside or in the office, which is critical for urgent surgical planning in this exposed implant scenario 1
• US can guide aspiration of any fluid collections for culture and cytology, which is essential given the high infection risk with implant exposure 1

Age-Specific Imaging Algorithm

The patient's age modifies the imaging approach slightly:

• If patient is under 30 years: Ultrasound alone is the recommended initial study 1, 2, 3
• If patient is 30-39 years: Either ultrasound or diagnostic mammography/DBT is acceptable as first-line imaging 1, 3
• If patient is 40 years or older: Diagnostic mammography or DBT may be considered first, but ultrasound remains most practical for acute implant exposure 1

Critical Clinical Context

Your patient's presentation—wound dehiscence with exposed implant after debridement—represents a surgical emergency requiring immediate management, not just routine implant evaluation. The imaging serves specific acute purposes:

• Rule out breast implant-associated anaplastic large-cell lymphoma (BIA-ALCL), which presents with delayed peri-implant effusion (>1 year post-surgery) and requires cytologic analysis of any fluid 1
• Identify fluid collections that need drainage before any salvage attempt 1
• Assess for extracapsular rupture that may have occurred during the debridement procedure 1
• Evaluate the capsule and surrounding tissue for masses or thickening that could indicate infection or other complications 1

When to Add MRI

MRI without contrast should be reserved for specific scenarios in your patient:

• If ultrasound findings are equivocal or indeterminate regarding implant integrity 1, 3
• If you need to assess for intracapsular rupture before deciding on implant salvage versus removal (though this is less urgent than managing the exposure) 1, 2, 3
• MRI has 82% sensitivity for detecting peri-implant effusion and 50% sensitivity for detecting masses, with specificities of 33% and 93% respectively 1

However, MRI should not delay urgent surgical management of the exposed implant 1, 3

Role of Mammography/DBT

Mammography or DBT has limited utility in your acute scenario:

• Cannot reliably detect intracapsular rupture and is primarily useful only for identifying extracapsular silicone 1
• May show nonspecific capsular thickening or asymmetry around the implant 1
• Sensitivity of only 73% and specificity of 50% for detecting abnormalities in implant complications 1

Critical Pitfalls to Avoid

• Do not delay imaging to obtain MRI when ultrasound can provide the necessary information for immediate surgical decision-making 1, 3
• Do not rely on the absence of leukocytosis to rule out infection—implant infections can occur without systemic signs, and the exposed implant itself is at extremely high risk for bacterial colonization 4
• Always obtain wound cultures during any surgical intervention, as pathogen identification (particularly atypical organisms like gram-negative rods, MRSA, or Candida) significantly affects salvage success rates 4
• If fluid is present on ultrasound, aspirate it for cytology to rule out BIA-ALCL, especially if the implant is textured 1

Surgical Management Context

The imaging findings will guide your surgical approach:

• Salvage of exposed implants is possible in selected cases (50-64% success rate) but requires specific conditions: adequate soft tissue coverage potential, no systemic wound healing problems, and appropriate pathogen profile 5, 6, 4
• Failed salvage is significantly associated with atypical pathogens (gram-negative rods, MRSA, Candida parapsilosis) on culture 4
• Negative pressure wound therapy combined with implant removal followed by early re-implantation has shown success in recent case reports, but requires complete bacterial clearance 7, 8