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Breast augmentation and implants — complications and BIA-ALCL
The commonest complication of breast implants, and the commonest reason for reoperation, is capsular contracture; a late seroma years after placement of a textured implant requires exclusion of BIA-ALCL — a T-cell lymphoma that is CD30 positive and ALK negative.
Why it matters in the exam
The implants: silicone or saline, smooth or textured, in a subglandular, subfascial or submuscular (dual plane) plane. Capsular contracture is graded by Baker: 1 — soft and normal, 2 — slightly firm, 3 — firm and visibly distorted, 4 — hard, painful and cold. Risk factors: subglandular plane, radiation, haematoma, subclinical infection and biofilm; treatment: capsulectomy and implant exchange, sometimes in a new plane. BIA-ALCL is linked to textured (not smooth) implants, appears on average 8 to 10 years after placement as a one-sided seroma or a mass; work-up: ultrasound, aspiration of the fluid for cytology, CD30 staining and flow cytometry; treatment: implant removal and complete (en bloc) capsulectomy, and in advanced disease systemic therapy as well.
Other deformities: "double bubble" when the implant lies below the new inframammary fold and the old fold shows; "bottoming out" — the implant drops below the fold; animation deformity with a submuscular implant; symmastia — the breasts join in the midline; superior malposition is treated by opening the capsule inferiorly. Silicone implant rupture is best diagnosed on MRI, and the FDA recommends MRI or ultrasound 5 to 6 years after placement and then every 2 to 3 years. A tubular breast (narrow base, "herniating" nipple) needs base release (scoring) and lowering of the fold, not just an implant. Poland syndrome — absence of the sternal head of pectoralis major, sometimes with symbrachydactyly of the same-side hand. Mondor disease is a superficial chest wall thrombophlebitis that resolves on its own. Before surgery, supplements that increase bleeding are stopped, such as garlic, vitamin E, ginkgo and ginseng.
Key points
- Capsular contracture — the commonest complication and reason for reoperation.
- BIA-ALCL — textured implant, late seroma, CD30.
- Treatment: implant removal and en bloc capsulectomy.
- Silicone rupture — MRI.
- Tubular breast — scoring and fold lowering.
Summary table
| Condition | Presentation | Work-up | Treatment |
|---|---|---|---|
| Capsular contracture | Firmness, pain, distortion (Baker 1 to 4) | Clinical | Capsulectomy and implant exchange |
| BIA-ALCL | Late seroma or mass, textured implant | Aspiration, CD30, flow | Implant removal and en bloc capsulectomy |
| Silicone rupture | Usually asymptomatic | MRI | Exchange or removal |
| Malposition | Double bubble, bottoming out, symmastia | Clinical | Pocket and capsule repair |
| Tubular breast | Narrow base, prominent nipple | Clinical | Scoring, fold lowering and implant |
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Sources
- US FDA: Breast implants — certain labeling recommendations and BIA-ALCL information, 2020 (updated) — Boxed warning, rupture screening and BIA-ALCL
- NCCN Consensus Guidelines on BIA-ALCL, 2025 — Diagnosis and treatment
- Israeli Ministry of Health circular on breast implant registry and follow-up, current — Patient information and follow-up
Sources are given for further reading; the text is written afresh and not copied from them.
Reviewed by the Examqo AI Professor · 2026-11-06. The text may contain errors; when in doubt, check the source.