Breast Implants: When to Reassure and When to Refer

Patients with breast implants are increasingly presenting in general practice. This article outlines common complications, key red flags and when specialist referral is warranted.

Prosthetic implants have been used for cosmetic breast augmentation since 1962.  Today, between 15,000 and 20,000 breast implant procedures (around 80% cosmetic) are performed annually in Australia, and increasing numbers of women present to general practice with implants in situ.

Most women with breast implants will not experience serious complications, but recognising the need for routine surveillance and identifying patients who require investigation and specialist management is important in primary care.

GPs therefore play a key role in assessing, monitoring and referring patients when implant-related concerns arise.

Breast implants are not lifetime devices. While some may remain asymptomatic for decades, the risk of complications increases over time.

Why patients have implants

Breast implants are used in several clinical contexts:

• Cosmetic breast augmentation
• Post-mastectomy breast reconstruction
• Correction of congenital breast or chest wall deformities
• Gender-affirming surgical procedures

All implants have a silicone shell, that is either smooth or textured to a varying extent, and most are also silicone gel–filled devices, although saline implants are also used. They may be round or anatomically shaped and are typically placed either above or beneath the pectoralis major muscle.

Common implant-related problems

Most complications encountered in primary care relate to local mechanical issues rather than systemic disease.

Capsular contracture

Capsular contracture is the most common reason for revision surgery. A fibrous capsule normally forms around an implant; however, in some patients this capsule progressively tightens, leading to:

• breast firmness
• shape distortion
• discomfort or pain

Symptoms usually develop several years after surgery but may occur earlier, particularly in the reconstructive setting.

From a clinical perspective, capsular contracture is commonly graded using the Baker classification:

• Grade I: Breast soft and natural
• Grade II: Breast slightly firm
• Grade III: Breast firm with visible distortion
• Grade IV: Breast firm, distorted and painful
• Grades I–II may be managed conservatively and monitored, while Grades III–IV typically warrant referral to a plastic surgeon for consideration of revision surgery.

Implant rupture

Implant rupture occurs when the implant shell fails and silicone gel escapes.

This may present with:

• change in breast shape or projection
• breast swelling or firmness
• deflation or loss of fullness
• axillary lymphadenopathy

However, many ruptures may be “silent” and asymptomatic.

Small intracapsular ruptures may initially remain contained within the surrounding capsule, but over time progress to extracapsular rupture, where silicone escapes beyond the capsule and may migrate into surrounding tissues or regional lymph nodes, making revision surgery more complex.

Breast ultrasound is the first-line investigation, with MRI used if imaging is inconclusive.

Patients with confirmed implant rupture should be referred to a plastic surgeon to discuss management options, which typically involve implant removal or replacement.  Adjunctive procedures such as mastopexy (breast lift) and lipofilling (autologous fat grafting) are often useful to consider.

Implant malposition and contour deformity

Implants may shift from their original position, producing contour abnormalities such as a “double bubble” deformity of the inferior pole or lateral displacement toward the axilla.

Visible implant edge “rippling” may occur in patients with thin soft-tissue coverage or following significant weight loss.

Shaped implants may occasionally flip or rotate, compromising breast shape.

Changes in breast tissue over time — with ageing, pregnancy or weight fluctuation — may produce a “waterfall” ptosis deformity, where native breast tissue descends over and below the implant.

Breast pain

Breast pain is common, including in patients with implants, and is often unrelated to the prosthetic device if capsular contracture is absent.

Differential diagnoses include:

• capsular contracture
• hormonally related mastalgia
• breast disease (most commonly benign)
• musculoskeletal chest wall pain

Assessment should follow standard breast pain evaluation once implant-specific complications have been excluded.

If clinical assessment and imaging do not reassure the patient, referral to a breast or plastic surgeon may be appropriate.

Breast implant illness

Breast implant illness (BII) is a term used by some patients to describe a constellation of systemic symptoms attributed to their breast implants.

Reported symptoms are diverse and may include:

• fatigue, arthralgia or myalgia
• dry eyes, skin rashes and hair loss
• anxiety, sleep or mood disturbances
• headaches, memory and concentration problems

Increasing numbers of patients present with these concerns, and GPs should take symptoms seriously and undertake a routine medical assessment to exclude other causes such as endocrine disorders, autoimmune disease, nutritional deficiency or mental health conditions.

Although BII is not currently recognised as a formal medical diagnosis and the causal mechanism remains unclear, a significant proportion of patients report improvement in symptoms following implant removal (explantation).

Referral to a plastic surgeon is appropriate for patients with persistent symptoms who wish to discuss explantation after appropriate medical evaluation to exclude other pathology.

Explantation surgery should ideally be performed by a plastic surgeon experienced in implant revision, the management of the surrounding capsules and skilled in techniques such as glandular re-shaping and fat grafting to help minimise the potential aesthetic consequences following implant removal.

Breast Implant–Associated Anaplastic Large Cell Lymphoma

Breast implant–associated anaplastic large cell lymphoma (BIA-ALCL) is a rare T-cell lymphoma associated with textured implants. It is not a breast cancer but arises from the capsule surrounding the implant.

The most common presentation is a late peri-implant seroma, causing unilateral breast swelling, typically 7–10 years after implantation.

Initial investigation includes breast ultrasound and aspiration of peri-implant fluid for cytology and immunohistochemistry (CD30 and ALK).

If cytopathology is negative for BIA-ALCL, routine plastic surgery review is still recommended to determine the underlying cause of the seroma and consider management options. If confirmed, urgent further imaging (MRI and PET-CT) is warranted, and the patient should be referred urgently to a multidisciplinary breast cancer team.

When diagnosed early, surgical treatment with implant removal and total ‘en bloc’ capsulectomy is usually curative. In around 25% of cases the disease involves the regional lymph nodes or has metastasised beyond and requires systemic therapy.

Red flags for GPs

The following symptoms should prompt early imaging and referral to a plastic surgeon or breast specialist:

• Late peri-implant seroma or acute unilateral breast swelling
• Rapid change in breast shape or implant position
• Progressive breast firmness or distortion
• Persistent unexplained breast pain
• Any palpable peri-implant mass
• Regional lymphadenopathy

These presentations may indicate implant rupture, severe capsular contracture, infection, or the rare but important BIA-ALCL.

Referral is also appropriate whenever clinical findings and imaging do not fully explain a patient’s symptoms, if there is ongoing patient concern, or if the treating doctor has any doubt about the diagnosis or best management.

Assessment in general practice

When assessing patients with implants, a focused history should include:

• indication and date of surgery
• implant details and operating surgeon (if known)
• breast symptoms (pain, swelling, or shape change)
• systemic symptoms
• breast cancer risk factors and screening history

Clinical examination should assess breast contour and symmetry, capsular firmness, palpable breast or peri-implant masses, and regional lymph nodes.

In many cases, a careful history, examination and targeted ultrasound are sufficient to reassure both patient and clinician.

Investigation and referral

Breast ultrasound is the preferred first-line imaging modality when implant complications are suspected.

If findings are equivocal, MRI is the most accurate second-line investigation.

Mammography may still be performed for breast cancer screening using implant-displacement techniques.

Referral to a plastic surgeon is appropriate for:

• suspected implant rupture
• symptomatic capsular contracture
• implant malposition or deformity
• persistent unexplained breast pain
• suspected BIA-ALCL
• suspected breast implant illness (BII)

Early specialist discussion can often clarify imaging findings and help guide management, particularly in patients with a complex implant history or prior breast surgery.

As more women live long-term with breast implants, familiarity with these presentations allows GPs to provide reassurance, recognise complications and facilitate timely specialist care.

Key Takeaways for GPs

1. Breast implants are not lifetime devices

Complications increase over time, particularly after 10 years. Capsular contracture is the most common reason for revision surgery.

2. Ultrasound is the first-line investigation

MRI is the most accurate second-line imaging for suspected rupture, peri-implant seroma or masses.

3. Late breast swelling is a red flag

Unilateral swelling years after implantation should prompt urgent investigation to exclude BIA-ALCL.

4. When in doubt, discuss or refer

If clinical assessment is uncertain, early discussion with or referral to a plastic surgeon can help guide further investigation and management.

Author

Dr Yez Sheena is a Specialist Plastic Surgeon based on the Gold Coast. He holds dual Fellowships of the Royal Australasian College of Surgeons and the Royal College of Surgeons of England and has undertaken advanced training in aesthetic surgery, oncoplastic breast surgery and microsurgical reconstruction. Dr Sheena has a specialist interest in aesthetic breast surgery, body contouring and reconstructive microsurgery and holds a public appointment at Gold Coast University Hospital, where he is the chair of the Breast Reconstruction multidisciplinary team.  He is actively involved in surgical education and has presented and published research nationally and internationally, and holds honorary academic titles at Griffith and Bond Universities. Dr Sheena consults privately in Southport at the Lotus Institute and the Queensland BreastCare Centre and welcomes referrals from GPs and specialists across a broad range of conditions including breast implant concerns, breast aesthetic and body contouring procedures, scar management, complex skin cancer and lymphoedema reconstruction.