In short
- Contracture: the breast hardens, rounds and rides up. The implant is fine; what changes is the capsule.
- Rupture of a saline implant: the breast deflates. The FDA describes it exactly that plainly — the saline is reabsorbed and the implant loses volume.
- Rupture of a gel implant: you may notice nothing at all. It is silent rupture, and imaging is needed to see it.
- 🔑 The scale used to grade contracture is not reliable between observers. Two surgeons examining the same patient agree on the grade only 48% of the time.
- The test that settles most is MRI, with an accuracy of 94% against 72% for ultrasound in the reference study.
- ⚠️ An increase in size appearing late on, with no blow and no infection, is always investigated. It is the sign that implant-associated lymphoma is looked for by.
- A contained rupture is not an emergency, but it is a reason to plan surgery, not to leave it indefinitely.
The difference shows above all in what has changed. Capsular contracture hardens the breast progressively and gradually lifts and rounds it: the implant is still whole and what contracts is the tissue around it. Rupture of a saline implant shows because the breast loses volume, sometimes within hours. And rupture of a silicone gel implant may give no symptom at all: that is what is called silent rupture, and it is only seen on imaging.
None of the three pictures is an emergency that means going to A&E tonight. All three are a reason to seek advice, and there is one that does call for investigation without delay: a breast that increases in size months or years after the operation.
This page sets out the signs that lead to considering the removal or exchange of implants.
Capsular contracture
A capsule of tissue forms around every implant. In most patients it is thin and gives no symptoms. In some it contracts, thickens and squeezes the implant: that is contracture.
How it shows, in the order it appears:
- The breast is firmer than it was, nothing more.
- It starts to look different: rounder, higher, with the fold less marked.
- It feels hard and the shape is no longer what it was.
- It hurts, or it is uncomfortable when lying down or exercising.
The classification used for decades sorts that into four grades, and this is how the FDA describes it: grade I, a soft breast of natural appearance; grade II, somewhat firm but of normal appearance; grade III, firm and of abnormal appearance; grade IV, hard, painful and of abnormal appearance. Grades III and IV are considered severe and may call for a further operation.
🔑 And here is a detail almost never mentioned: that scale is not reliable as a diagnostic tool. In a study in which sixty women who had had surgery were examined independently by two plastic surgeons, agreement between observers was 48%; in 43% of cases they differed by one grade and in 12%, by more than one. Overall reliability was poor (kappa 0.55).
⚠️ It does not mean that contracture does not exist or that the grade does not matter. It means that a label such as “you have a grade III” is not an objective fact but a judgement, and that if one surgeon tells you grade II and another grade III it is not that one of them is wrong: it is a scale with that measured spread. What decides the indication is what is happening to you —hardness, shape, pain— and not the number.
Rupture
An implant rupturing does not mean it bursts. It means the shell loses its integrity, and what happens next depends on what it is filled with.
Saline implants
You notice it. The saline escapes and the body reabsorbs it, so the breast deflates —immediately or over a few days— and the asymmetry is obvious. The FDA describes it exactly that way. It is not dangerous: saline is harmless. It is a reason to operate, not an emergency.
Silicone gel implants
Here is what causes the confusion. Current gel is cohesive and, when the shell ruptures, it usually stays inside the capsule. It is called intracapsular or contained rupture, and it often produces no symptom at all: the breast stays the same and the patient notices nothing. It is silent rupture.
When the gel crosses the capsule —extracapsular rupture— a change of shape, a lump, discomfort or a swollen lymph node in the armpit can appear.
⚠️ Time counts. The probability of rupture increases with the years the implant has been in place, and that is why noticing nothing does not amount to everything being fine after a decade. In a prospective series of 50 women who were explanted, rupture was identified during surgery in 34 of them (68%) — a high figure that has to be read carefully: they were patients who had already decided to have surgery, not a sample of implant carriers.
Which test settles it
Imaging is what separates suspicion from fact.
The FDA says it without ambiguity: magnetic resonance imaging is the most effective method for detecting silent rupture of silicone gel implants, and ultrasound is an acceptable alternative for screening in patients without symptoms.
The figures from the reference study quantify it: an overall accuracy of 94% for MRI against 72% for ultrasound, and a negative predictive value of 85% for ultrasound — that is, a normal ultrasound scan makes it possible in many cases not to need the MRI.
⚠️ That study was done in patients reconstructed after mastectomy, not in aesthetic augmentation. The figures for how the test performs carry over with caution; its proposed screening schedule does not carry over here, because the population is a different one.
And there is one test that is no use for this: the mammogram. It detects other things well, and that is why it is still done within the screening programme, but it is not the test for assessing whether an implant is intact.
🔑 And this practice’s schedule, which is what almost no website publishes: an annual check-up with ultrasound. It is the follow-up test, for availability and because it involves no radiation. Where there are signs that raise a suspicion of rupture, MRI follows to confirm the finding.
⚠️ That order matters. MRI is more accurate, but it is not the monitoring test: it is the confirming one. Using it from the start at every check-up would add nothing and would multiply the cost and the waiting.
The sign that must not be let pass
Of everything above, there is one that deserves a paragraph of its own.
🚨 A breast that increases in size months or years after surgery, with no blow and no infection to explain it, is investigated. It is usually fluid collected around the implant —a late seroma— and although most of the time it is nothing serious, it is the commonest way breast implant-associated anaplastic large cell lymphoma presents. In Spain there is an official protocol for detecting it, drawn up by the AEMPS advisory commission together with experts in Medical Oncology and Haematology, updated in 2024.
To put it in proportion without alarm: in its sixth report, published on 3 June 2026, the AEMPS reports 146 notifications of suspected cases and 111 confirmed cases up to 2025 across the whole country.
What to do: seek advice without leaving it, and say expressly when it started. What is not appropriate is to drain it and forget about it: the fluid is analysed. The page on BIA-ALCL sets it out in full.
What is done in each case
| What you notice | What it usually is | What is done |
|---|---|---|
| The breast hardens and rides up little by little | Capsular contracture | Examination; surgery if it is symptomatic or deforming |
| The breast has deflated | Rupture of a saline implant | Exchange or removal, planned |
| I notice nothing but I have had them many years | Possible silent rupture | Ultrasound and, if there are doubts, MRI |
| A lump, a change of shape or a node in the armpit | Possible rupture with silicone outside | MRI and assessment |
| The breast has increased in size recently | Late seroma | Analysis of the fluid, without delay |
| Pain, redness and fever | Possible infection | Seek advice the same day |
⚠️ None of these situations means having surgery the same month, except infection and a late seroma awaiting investigation. What is advisable is not to leave a confirmed rupture indefinitely: the longer the gel is outside the implant, the harder it usually is to clean up afterwards.
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Frequently asked questions
How do I know whether an implant has ruptured?
It depends on the filling. If it is saline, you notice it because the breast deflates. If it is silicone gel, often you notice nothing at all —that is silent rupture— and imaging is needed to see it. A change of shape, a new lump or a swollen node in the armpit are reasons to seek advice.
Is it dangerous to have a ruptured implant?
A rupture contained inside the capsule is not a life-threatening emergency and does not oblige you to have surgery that week: the operation is planned. 🔑 And it is worth dismantling a very widespread fear: waiting does not complicate the operation. With implants of the current generations, the silicone still stays inside the capsule, so the time that has passed does not make the exchange any harder. What is reasonable is not to put it off indefinitely.
What is capsular contracture, and how would I know I had it?
It is the contraction and hardening of the capsule of tissue surrounding the implant. You notice it because the breast is firmer, rounds off, rides up and in advanced cases hurts. The implant itself is whole: what has changed is what is around it.
Are the grades of contracture objective?
Not as much as they seem. The scale used —the Baker classification— has been measured and turns out to be unreliable between observers: two surgeons examining the same patient agree on the grade 48% of the time, differ by one grade 43% of the time and by more than one 12% of the time. What decides whether to operate is the clinical picture —hardness, deformity, pain— more than the label.
Which test will I be asked for?
Usually ultrasound as a first approach, and magnetic resonance imaging when there are doubts or when what is being looked for is a silent rupture. The FDA considers MRI the most effective method for that rupture and ultrasound an acceptable alternative for screening in patients without symptoms.
And as routine follow-up, an annual ultrasound is done here; if something appears that raises a suspicion of rupture, it is confirmed with MRI.
Is a mammogram any use for seeing whether the implant is ruptured?
It is not the test for that. The mammogram is still done within whichever breast cancer screening programme is due by age, but for assessing whether the implant is intact, ultrasound and MRI are used.
One of my breasts has grown suddenly — what do I do?
Seek advice, and say when it started. If months or years have passed since the surgery and there is no blow and no infection to explain it, it is the situation that calls for the fluid to be analysed rather than simply drained. The vast majority of the time it is nothing serious, and for that very reason the investigation is quick to do.
Can the contracture come back if I have surgery?
Yes. In the most cited series, the contracture recurred in 22.7% of the patients treated for it, and the risk was significantly greater in those whose gel implant was ruptured. It is set out in full in the page on exchange or removal.
Sources
- Risks and Complications of Breast Implants. U.S. Food and Drug Administration, updated 14 December 2023. fda.gov — Magnetic resonance imaging is the most effective method for detecting silent rupture of silicone gel implants and ultrasound is an acceptable alternative for screening in asymptomatic patients. It also describes the noticeable deflation of saline implants and the four grades of capsular contracture, with grades III and IV considered severe and open to a further operation. Checked on 05-09-2026.
- de Bakker E, Rots M, Buncamper ME, et al. The Baker Classification for Capsular Contracture in Breast Implant Surgery Is Unreliable as a Diagnostic Tool. Plastic and Reconstructive Surgery. 2020;146(5):956-962. PMID 32852468 — Sixty women who had had augmentation surgery, examined independently by two plastic surgeons. Poor interobserver reliability (kappa 0.55; 95% CI 0.37-0.72), agreement of 48%, a difference of one grade in 43% and of more than one in 12%. Checked on 05-09-2026.
- Rietjens M, Villa G, Toesca A, et al. Appropriate use of magnetic resonance imaging and ultrasound to detect early silicone gel breast implant rupture in postmastectomy reconstruction. Plastic and Reconstructive Surgery. 2014;134(1):13e-20e. PMID 25028829 — Overall accuracy of 94% for MRI and 72% for ultrasound, with a negative predictive value of 85% for ultrasound. Level of evidence II. ⚠️ A population of reconstruction after mastectomy, not of aesthetic augmentation; this page carries over how the test performs and not its proposed screening schedule. Checked on 05-09-2026.
- Gigov K, Ginev I, Kavradzhieva P, Miteva M. Patient-Reported Symptom Changes Following Breast Implant Explantation with Total Capsulectomy: A Prospective Case Series of 50 Patients. Healthcare (Basel). 2026;14(16):2603. PMID 42651372 — Rupture identified during surgery in 34 of 50 patients (68%), with a mean age of 43 at explantation. ⚠️ A series without a control group and with mostly self-referred patients: it is not an estimate of prevalence among implant carriers, and this page says so. Checked on 05-09-2026.
- Swanson E. Open Capsulotomy: An Effective but Overlooked Treatment for Capsular Contracture after Breast Augmentation. Plastic and Reconstructive Surgery – Global Open. 2016;4(10):e1096. PMID 27826488 — 75 women treated for contracture; recurrence in 22.7% and a significantly greater risk with ruptured gel implants (p = 0.01). A single-surgeon series. Checked on 05-09-2026.
- Follow-up of the protocol for the detection in Spain of anaplastic large cell lymphoma (ALCL) associated with breast implants. Sixth report. Spanish Agency of Medicines and Medical Devices (AEMPS), 3 June 2026. aemps.gob.es — 146 suspected notifications and 111 confirmed cases up to 2025; detection protocol drawn up in 2019 and updated in 2024. Checked on 05-09-2026.
Book your consultation
If your breast feels different and you do not know whether it is something to do with the implant or with the capsule, examination points the way and an ultrasound scan usually settles it. If what has changed is the size and it is months or years since the operation, do not leave it: that is the one worth looking at soon.
Clinical confirmation by the surgeon
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