How to diagnose a suspected ruptured breast implant in a patient after a fall?

Diagnostic Approach to Suspected Breast Implant Rupture After Trauma

MRI without contrast is the definitive imaging study for evaluating suspected silicone implant rupture after a fall, with sensitivity of 87% and specificity of 89.9%. 1

Initial Imaging Selection Based on Implant Type

For Silicone Implants (Most Common Scenario)

Order MRI without contrast as the primary diagnostic test. 2, 1 This is the FDA-recommended imaging modality for symptomatic patients with silicone implants and provides the most accurate assessment of both intracapsular and extracapsular rupture. 2

• Clinical examination is unreliable for detecting implant rupture and should never be used as the sole diagnostic method. 2, 1
• Physical findings such as breast asymmetry, palpable masses, or contour changes warrant imaging but cannot confirm or exclude rupture. 2

For Saline Implants

Use ultrasound as the initial examination if the patient is under 30 years old. 1 For patients 30-39 years, either mammography/digital breast tomosynthesis (DBT) or ultrasound may be used first. 1 For patients 40 years and older, mammography or DBT is first-line. 1

• MRI has no role in saline implant evaluation, neither with nor without contrast. 1
• Saline implant rupture is typically obvious clinically (sudden deflation) and easier to diagnose than silicone rupture. 3

Understanding MRI Findings for Silicone Implants

Intracapsular Rupture Signs

• "Linguini" or "wavy-line" sign: Most specific for complete intracapsular rupture, representing collapsed implant shell floating within the fibrous capsule. 1, 4
• "Inverted-loop," "keyhole," "teardrop," or "hang noose" signs: Indicate incomplete intracapsular rupture. 1, 4

Extracapsular Rupture Signs

• Extravasated silicone in breast tissue or axillary lymph nodes confirms extracapsular rupture. 1
• This finding requires urgent referral to plastic surgery within 2-4 weeks. 4

Alternative Imaging When MRI is Contraindicated

If the patient cannot undergo MRI (pacemaker, severe claustrophobia, aneurysm clips), use the following approach: 5

Mammography or Digital Breast Tomosynthesis

• Can identify extracapsular silicone appearing as high-density material outside the implant shell. 2
• Obtain both standard views (craniocaudal and mediolateral oblique) AND implant-displaced views. 2
• Cannot detect intracapsular rupture, which represents the majority of implant ruptures. 2, 6
• Compare with prior imaging, especially if the patient had previous silicone implants, to distinguish new rupture from residual silicone. 2

Ultrasound

• If more than 2 signs of rupture are present on ultrasound, findings can be acted upon without MRI confirmation. 2, 4
• If only 1 sign of rupture is found, MRI is needed for confirmation. 2, 4
• Recent data shows ultrasound can achieve diagnostic accuracy of 94.7% when performed by experts. 2
• However, older studies showed much lower sensitivity (30%) and accuracy (72%) for intracapsular rupture, so expertise is critical. 2
• Ultrasound findings include "stepladder" appearance of collapsed implant shell. 2

Critical Pitfalls to Avoid

• Do not rely on clinical examination alone – it is notoriously unreliable for detecting rupture. 2, 1
• Do not order MRI with contrast for implant evaluation – contrast adds no value for assessing implant integrity and is unnecessary. 4
• Do not assume capsular calcifications indicate rupture – they correlate with implant age but not rupture status. 1
• Beware of ultrasound mimics including reverberation artifact, radial folds, or silicone implant impurities that can falsely suggest rupture. 6
• Do not delay imaging in symptomatic patients – trauma increases rupture risk, and iatrogenic damage is the most frequent cause of rupture. 7

Clinical Context After Trauma

Trauma from a fall can cause immediate rupture or accelerate pre-existing subclinical rupture. 7 The patient's symptoms (pain, swelling, asymmetry, palpable changes) increase the pre-test probability of rupture significantly compared to asymptomatic screening scenarios. 8, 9

• In symptomatic patients with implants >10 years old, rupture prevalence is approximately 64%. 9
• In symptomatic patients with implants ≤10 years old, rupture prevalence is approximately 31%. 9
• These high pre-test probabilities make positive imaging findings highly reliable and justify proceeding directly to surgical consultation. 9

Urgency of Referral Based on Findings

• Extracapsular rupture: Refer to plastic surgery within 2-4 weeks for evaluation and surgical planning. 4
• Intracapsular rupture only: Less urgent, but patient should still be referred for surgical consultation as the fibrous capsule may be compromised and at risk for progression. 4
• Herniation or bulging: Represents weakening of the fibrous capsule and potential weak points, making this more urgent than typical asymptomatic intracapsular rupture. 4