What is your recommendation for a patient with a possible intracapsular leak from a silicone implant,noted on a routine mammogram? Patient doesn't complain of feeling anything.

I would get an MRI first if the patient really wants to keep the original implants, particularly if they are less than 10 years old. However, I have been burned more than once with MRI positive leaks that ultimately had intact implants. Most of the patients I see like this had their implants put in 25 years ago. In these patients if it isn't leaking, it will be soon, and I would encourage removal. If the patient is older and is not as concerned about the appearance of her breasts, I would recommend that she just remove them and be done with it. Medicare and other insurance companies will, in my experience, cover removal of leaking implants (but not replacement). If she wants implant replacement then I would not get an MRI, just replace them.

MRI is the definitive study for possible ruptured silicone implants .If they are ruptured, capsulectomy must accompany the removal of the implants. The mammogram's quality is as important as the experience of the surgeon for determining the need for surgery. Replacement of the implants is a patient option independent of age.

I would only suggest an MRI if she wants to keep her implants. Otherwise, if they are the old versions, I would remove them with a capsulectomy before replacing them with a new set. I agree with ER Cath regarding Medicare patients.

Continue routine checks until patient becomes symptomatic

How about recommending implant removal with/without exchange, since MRI increases cost?

If she wants the implants out anyway, there is no need for an MRI. I would recomment capsulectomies if the inside of the capsules are "sticky" prior to implant exchange.

I agree that the literature specifies MRI for the diagnosis of silicone implant rupture. If the patient is however anxious and physical exam reveals true rupture then she may forgo MRI and you may consider performing implant exchange.