For saline prostheses, the most common sign associated with implant rupture is the evidence of volume diminution, which can be acute or gradual. There is rarely pain with a saline implant rupture outside of the infrequent post-traumatic ruptures. In silicone prostheses, some degree of chest wall pain may be present as the granulomatous inflammatory reaction takes place. A saline implant rupture is easy to detect on physical examination. It is often referred to as a deflated breast. It decreases in size over the course of a few days. If the saline implant deflates within a few days of insertion is it suggestive of iatrogenic damage or an improperly closed valve. For a mature implant, a recent history of trauma could be the cause of the rupture; but in the absence of this, manufacturing defects may be responsible, or late-stage implant failure may indicate the end of the lifespan of the implant. Silicone implant rupture is difficult to detect on physical examination, with a majority of cases being intracapsular, further evaluation with imaging is often required. Extracapsular silicone implant ruptures can sometimes produce a palpable mass or irregularity of the breast as inflammation and granulomatous tissue form; alternately, they may present with vague pain or tenderness symptoms or may be completely asymptomatic.Lymphoma has also been reported in association with a certain subset of breast implants, so the astute surgeon must always remember to query the patient regarding axillary or local masses and systemic symptoms that could herald lymphoma.

Pertinent questions for the suspected implant rupture are therefore:

• When was the implant placed?
• What type of implant was placed (if known)?
• Onset/duration of any symptoms
• Fevers/chills, or B-symptoms

Pertinent physical examination findings include:

• Breast shape and symmetry
• New breast masses
• Associated lymphadenopathy in the axillae or elsewhere
• The texture of the breast implant in question versus the contralateral breast implant
• Skin changes in the affected breast versus the contralateral breast
• Niple discharge

A saline implant rupture often requires no radiographic evaluation. As described above, a simple clinical evaluation demonstrating volume loss is sufficient. If mammography imaging is obtained, then the implant will often demonstrate a wrinkled appearance. An intact implant will demonstrate a simple anechoic interior on ultrasound, while a rupture will demonstrate folds or wrinkles in the implant capsule. MRI will show a saline implant follow fluid signal on all sequences.[9][10][11]

An intracapsular silicone implant rupture is very difficult to see on mammography. A bulging of the implant contour can suggest an intracapsular rupture. Ultrasound lacks sufficient sensitivity to show intracapsular ruptures, as the silicone is relatively hypoechoic and produces significant artifact on imaging. The most reliable finding is called a stepladder sign, in which multiple, linear echoes are noted in the implant. MRI is the most sensitive at detecting silicone implant rupture. The demonstration of silicone on both sides of a radial fold is known as the keyhole, noose, or teardrop sign (all referring to the same finding). The finding of multiple folds of the implant shell layering upon itself is referred to as the linguine sign and highly indicative of an intracapsular rupture. This should not be confused with the normal radial folds/creases of an implant, which are often straight, thick, short, and extend to the periphery of the shell. CT imaging will also demonstrate the characteristic linguine sign, but with an overall low sensitivity and high radiation dose is not used to evaluate implant rupture. It is often incidentally seen on CT.

Extracapsular rupture can often be seen with mammography and ultrasound, showing the extravasated silicone in the surrounding tissues or even axillary lymph nodes. The snowstorm sign is a sonographic finding of silicone gel droplets mixed with breast tissue showing a heterogeneous echogenic appearance resulting from the dispersion of the ultrasound beam. MRI is still the modality of choice to determine the extent of the extravasation. The silicone will have low signal on T1, and a high signal on T2 fat-suppressed images. Computed tomography is not used to evaluate extracapsular rupture because the silicone and the surrounding soft tissues which demonstrate a similar radiodensity

The empty shell of a ruptured saline implant should be removed. A ruptured silicone implant, whether intracapsular or extracapsular, should be removed because of the possible interaction with surrounding tissue and possible spread to local lymph nodes. Replacement with a more modern implant, whether silicone or saline, should be offered. Asymptomatic patients may be reluctant to undergo this procedure, but the overall long-term safety should be emphasized and the risk of malignancy discussed. If an intracapsular rupture occurs, then a capsulectomy can be performed. If all silicone has been cleaned (if the rupture was very recent, this is possible), the surgeon may not remove the fibrous capsule. If there is a doubt about silicone persistence, the surgeon should attempt to remove the entire fibrous capsule that has been infiltrated by silicone. A capsulectomy will be necessary in case of calcification. If the rupture is extracapsular, then it is possible that the patient will need several surgeries to retrieve all of the extravasated silicone gel, with a delayed replacement of the implant to restore normal breast contour.

• Damage by a surgical instrument

• Needle insertion during a biopsy

• Normal ageing of implant

• Trauma caused by a car accident

Breast implants have an expiration date and a lifespan, and may need to be replaced to avoid complications such as implant rupture. The rate of implant rupture can be directly related to the age of the implant (in the absence of obvious, severe, trauma). With over 3.5 million breast implants in the United States, it is imperative for medical professionals to understand the common presentation, diagnostic exams, common imaging findings, and management.

Breast implants are not permanent and have a definitive lifespan that varies from 12-35 years. With advancing age, they have the potential to rupture and hence all healthcare workers should be familiar with the work up. These patients are best managed by the plastic surgeon. Once an implant has ruptured, it needs to be surgically removed. In some cases, several procedures are required to completely remove the implant and the adjacent fibrosis. [12]