Synopsis
Assess symptoms around a reconstructed breast implant, distinguish urgent infection from structural complications and investigate late swelling without missing capsule-associated malignancy.
- A painful red reconstructed breast, fever, wound discharge or implant exposure needs prompt reconstructive-team assessment. Suspected deep pocket infection requires antimicrobial treatment and a source-control decision; a cellulitis prescription alone is insufficient.
- For a persistent new peri-implant seroma more than one year after insertion, arrange urgent ultrasound and purposeful sampling for cytology and appropriate haematopathology, specifically raising BIA-ALCL. Do not simply drain and discard the fluid.
- Ultrasound is the initial implant-complication study; equivocal rupture findings warrant dedicated non-enhanced implant MRI. Painful firmness and distortion may represent contracture but a new fluid collection or mass needs separate assessment.
Key red flags
Look for spreading warmth and erythema, escalating pain, wound discharge, dehiscence and visible or threatened implant exposure. Fever, tachycardia, hypotension or systemic deterioration increase urgency, but a patient can have a clinically important infected pocket without all of those signs. Inspect the quality of the covering skin and consider an underlying collection. Contact the responsible breast or plastic surgical service promptly and use emergency assessment for systemic illness. A superficial skin response to antibiotics does not prove that a deeper collection or contaminated device has been dealt with.
Investigation priorities
For late persistent swelling, obtain urgent expert ultrasound to identify fluid, a capsular mass and relevant nodes. Arrange image-guided aspiration with the laboratory pathway agreed in advance; clearly state concern for BIA-ALCL.
Management branches
Twelve days after reconstruction, a woman has increasing pain, purulent drainage and a small wound opening with the implant visible. Ultrasound shows peri-implant fluid.
- The assessing clinician obtains observations, checks the remaining skin coverage and contacts the reconstructive surgeon urgently. The combination of purulent fluid and exposure establishes a source-control concern even though her blood pressure is currently normal; she is admitted rather than given an isolated community cellulitis course.
- The surgical team provides antimicrobial treatment and takes her to theatre for drainage, debridement and removal of the exposed infected device after assessing the pocket and non-viable covering tissue. Fluid and tissue are sent for microbiology. Keeping the implant would leave the identified source and inadequate coverage unresolved in this case.