Precautions for intercostal catheter insertion in breast implant patients: a rare case report and literature review

Introduction

Background

Intercostal catheter (ICC) insertion is a critical intervention for managing pneumothoraces, hemothoraces, and pleural effusions (1-3). While widely considered safe, this procedure carries additional risks in patients with breast implants due to their proximity to the pleural space (3,4). Standard ICC placement is guided by the “triangle of safety”, defined as the area between the lateral border of the pectoralis major, the anterior border of the latissimus dorsi, and the fifth intercostal space above the nipple line (5-8). However, in patients with breast implants, this anatomical landmark may require modification to prevent inadvertent implant injury. Breast implant rupture is a significant complication, potentially leading to pain, infection, aesthetic deformity, and capsular contracture (9). Breast reconstruction with implants can be performed using either a submuscular or a pre-pectoral approach (9). In the submuscular technique, the implant is placed beneath the pectoralis major muscle, providing greater coverage. In the pre-pectoral technique, increasingly popular in recent years, the implant is positioned above the muscle and directly beneath the skin and subcutaneous tissue (9). While the pre-pectoral approach improves aesthetic outcomes and recovery time, it also places the implant in closer proximity to the chest wall, increasing its vulnerability during thoracic procedures. Common complications of breast implants include rupture, infection, capsular contracture, and displacement (9). In cases of hemothorax, where the ICC must be directed basally for efficient drainage, the risk of damaging the implant increases (5-7).

Rationale and knowledge gap

Despite the widespread use of ICC insertion in clinical practice, there is a notable lack of literature addressing safe techniques for ICC placement in patients with breast implants, particularly those with pre-pectoral positioning. Existing reports are limited and often anecdotal, with no standardized guidelines for catheter positioning to avoid implant injury. This manuscript differs from previous case reports by demonstrating how a minor yet deliberate adjustment, shifting the insertion point 1 cm superior to the conventional “triangle of safety”, can effectively preserve implant integrity. Our findings support the need for individualized anatomical assessment and suggest practical modifications to standard protocols in this unique patient population.

Objective

This case report and literature review aim to highlight the procedural risks associated with ICC insertion in breast implant patients and to present a practical solution. Specifically, we describe how a 1-cm superior adjustment of the insertion site, based on pre-pectoral implant positioning, successfully avoided implant rupture. This case contributes to the limited literature by providing a reproducible technique and emphasizing the need for individualized planning in similar scenarios (Figure 1). We present this article in accordance with the CARE reporting checklist (available at https://abs.amegroups.com/article/view/10.21037/abs-25-12/rc).

Figure 1 Schematic diagram illustrating the recommended insertion of the ICC at the uppermost aspect of the safety triangle in patients with pre-pectoral breast implants. Markings indicate the adjusted site 1 cm superior to standard landmarks. ICC, intercostal catheter.

Case presentation

All procedures performed in this study were in accordance with the ethical standards of the institutional and/or national research committee(s) and with the Declaration of Helsinki and its subsequent amendments. Written informed consent was obtained from the patient for the publication of this case report and accompanying images. A copy of the written consent is available for review by the editorial office of this journal.

A 72-year-old female with a history of breast cancer and prior unilateral breast reconstruction presented to the emergency department with a short history of dyspnea and pleuritic chest pain. The patient had undergone a mastectomy and subsequent implant-based reconstruction on her right breast five years prior. Notably, the breast implant was a silicone gel prosthesis placed in a pre-pectoral position, situated above the pectoralis major muscle and directly beneath the subcutaneous tissue. On admission, her vital signs were stable, but she exhibited decreased breath sounds on auscultation of the right lung field, and a chest X-ray revealed a moderate right-sided hemothorax. A CT scan confirmed the presence of pleural fluid without evidence of active bleeding, and no apparent disruption of the breast implant was detected.

Given the clinical findings, an ICC was indicated for hemothorax drainage. Standard practice dictated insertion within the triangle of safety; however, careful consideration was required due to the pre-pectoral placement of the breast implant, and the anatomical landmarks were carefully re-evaluated due to the presence of the breast implant. This decision was guided by pre-procedural imaging, including CT and bedside ultrasound, which helped assess the spatial relationship between the implant and the pleural space. Although real-time ultrasound was not used for catheter insertion, the anatomical assessment provided by imaging allowed for safe planning of the entry site. The ICC was placed using a blunt dissection technique, and post-procedural imaging confirmed the correct positioning of the catheter while preserving the integrity of the implant. The patient was monitored closely, and serial imaging confirmed the resolution of the hemothorax without complications (Figures 2,3).

Figure 2 CT chest coronal view showing pigtail ICC. CT, computed tomography; ICC, intercostal catheter.

Figure 3 CT chest axial view showing ICC placement in relation to the left breast implant. CT, computed tomography; ICC, intercostal catheter.

Following ICC removal three days after insertion, the plastic surgery team evaluated the patient, and subsequent ultrasound imaging confirmed no evidence of implant rupture. She remained asymptomatic, with no signs of infection or capsular contracture during 6 months follow-up.

Literature review

ICC insertion and breast implant complications

Few studies specifically address ICC placement in patients with breast implants (1). However, the risk of pneumothorax and implant rupture during thoracic interventions has been documented in the literature (2).

Breast implant rupture is usually iatrogenic or due to trauma. A rare case was described where a breast prosthesis ruptured due to emergency ICC insertion in a patient with blunt chest wall trauma. Whilst the mechanism of injury is somewhat confounding, the authors concluded that intrathoracic visualisation is important when performing intrathoracic procedures in patients with breast implants (3).

A study that surveyed plastic surgeons found that one in three had encountered at least one case of pneumothorax following breast augmentation surgery (4). The most common cause was reported to be unexpected pleural laceration during dissection or needle puncture during local anesthetic injection. This highlights the vulnerability of the pleura and the need for meticulous technique during thoracic interventions in breast implant patients (5-8).

Another case report described an iatrogenic tension pneumothorax occurring 6 hours post-breast augmentation (5). The suspected cause was local anesthetic infiltration using a long spinal needle, inadvertently penetrating the pleura. This underscores the importance of careful needle use and avoidance of deep penetration when performing procedures in proximity to breast implants.

While not directly related to ICC placement, prior reports of barotrauma during implant insertion highlight how anatomical changes associated with breast augmentation may predispose patients to thoracic complications. This reinforces the need for caution and individualized planning during intercostal procedures in patients with breast implants (6). In a follow-up study conducted in 2007, Fayman analyzed the role of air drainage in preventing pneumothorax during breast augmentation and found that draining air from the surgical cavity effectively prevented its occurrence (7). The results suggested that air drainage should be routinely implemented, especially in procedures involving large implants and small incisions.

Furthermore, even with no pre-existing chest wall vulnerabilities, there is still considerable risk associated with intrathoracic procedures in patients with pre-existing breast implants. This was highlighted in a reported case of a patient who underwent video-assisted thoracoscopic surgery (VATS). As a result, there was intrathoracic migration of the patient’s breast implant despite them having no preoperative issues and undergoing a video-assisted procedure (VAP) (8). This highlights the importance of carefully considering the potential risks of implant displacement during thoracic surgeries, even in patients without prior complications.

Similarly, the use of VAPs has been shown to reduce complication rates and enhance outcomes in submuscular breast reconstruction procedures compared to non-video-assisted methods (9). Whilst the use of VAP has been shown to reduce complications and enhance outcomes during invasive thoracic procedures, it may not always be practical or available during emergencies.

Ultrasound guidance for ICC placement

Ultrasound-guided procedures are becoming increasingly common globally and are being used more frequently to guide invasive procedures. Since 2010, non-radiologists have performed more ultrasound-guided procedures than radiologists (10). Ultrasound may prove to be a viable intra-procedural method for safe ICC insertion, especially in patients with breast implants.

Ultrasound guidance has been widely recommended in various procedures to reduce complications. A Cochrane review by Brass et al. [2015] reported that ultrasound guidance for internal jugular vein (IJV) catheterization reduced the total complication rate by 71% compared to anatomical landmark techniques (11). Given the success in IJV catheterization, ultrasound for ICC insertion in breast implant patients may improve safety by enabling the visualization of essential structures.

Further, a systematic review compiling 20 studies found that ultrasonography was an adequate tool in diagnosing breast implant rupture when compared to gold standard surgical findings: pooled sensitivity, 73.7% [95% confidence interval (CI): 70.2% to 77.1%]; pooled specificity, 87.8% (95% CI: 86.5% to 89.0%). Given the efficacy of ultrasound in diagnosing breast implant rupture, utilizing ultrasound during ICC placement in breast implant patients may reduce complications by enabling adequate visualization of important surrounding structures (12). In addition to evaluating implant integrity, imaging modalities such as ultrasound and CT also help confirm proper catheter placement, particularly in relation to the pleural space and surrounding structures. This is especially important in patients with altered anatomy due to implant positioning.

Discussion

This case, along with selected reports from the literature, highlights the need for potential modifications to standard ICC insertion techniques in patients with breast implants, especially in those with pre-pectoral positioning. The risks associated with thoracic procedures in patients with breast implants, such as infection, pneumothorax, or displacement, warrant a more cautious and tailored approach (1,2,13). Although implant rupture is rare, anatomical proximity during intercostal interventions justifies heightened attention. Given the anatomical changes introduced by breast implants, standard ICC insertion methods, which rely on the triangle of safety, may not provide adequate protection against complications. As such, adjusting the anatomical landmarks, such as repositioning the safety triangle by 1 cm superiorly, can reduce the risk of implant rupture and pleural injury. Although not universally validated, this adjustment was based on direct anatomical assessment of the implant’s position relative to the chest wall and was successful in this case. The rationale for the 1-cm superior shift is based on direct anatomical observation: in patients with pre-pectoral implants, the superior margin of the implant often lies just below the conventional insertion point within the triangle of safety. By slightly adjusting the site upward, clinicians can increase the distance between the ICC and the implant, especially in slim patients or in those with low-profile reconstructions. Although no formal studies have evaluated this approach, our case demonstrates its practical effectiveness. In our case, this simple adjustment was likely decisive in avoiding implant rupture, as the final catheter position was located just above the superior pole of the implant. This reinforces the clinical utility of adapting the insertion site based on implant anatomy, even when using standard surface landmarks. In patients with pre-pectoral implants, where the device is located more superficially, even standard landmark-based approaches may place the implant at risk. Pre-procedural imaging, including CT or ultrasound, is crucial in assessing the position of the implant and pleural space, ensuring safer ICC insertion and reducing the risk of inadvertent damage (14,15). In our patient, this step was fundamental in visualizing the anterior margin of the pre-pectoral implant and determining a safe superior approach to avoid contact during catheter insertion.

Ultrasound guidance has become standard practice in various thoracic procedures and is underutilized in ICC placement (16). Its application could significantly enhance safety in patients with breast implants by allowing direct visualization of vital structures, such as the pleura, chest wall, and implant. The literature supports that ultrasound-guided ICC insertion can reduce pneumothorax rates, misplacement, and complications (17,18). By providing real-time imaging, ultrasound can assist clinicians in avoiding inadvertent damage to the implant and surrounding structures, making it an invaluable tool for improving outcomes in these patients.

Post-procedural imaging is often overlooked in routine ICC placements. Still, it plays a critical role in ensuring implant integrity and identifying potential complications that may arise after the procedure. As demonstrated in this case, ultrasound, CT or magnetic resonance imaging (MRI) imaging should be considered after ICC insertion to confirm correct catheter placement and assess the implant’s condition. Without this, complications such as implant rupture, capsular contracture, or infection may go unnoticed, leading to delayed treatment and increased morbidity. Additionally, non-breast implant complications such as tube kinking, obstruction, or entrapment in the major fissure can be detected and thus corrected with post-procedural imaging (19). Routine post-procedural imaging can help identify and address these issues early, preventing long-term complications and improving patient outcomes. In this case, serial ultrasound imaging post-insertion confirmed both appropriate catheter positioning and the absence of implant rupture or capsular disruption. The choice of imaging modality should be tailored to the type of implant: silicone gel implants, like in our case, are best evaluated using ultrasound or MRI, as CT is less sensitive for detecting silent ruptures. Conversely, saline implant rupture can typically be diagnosed through physical examination due to the visible deflation of the prosthesis (3,4).

The pre-pectoral placement of breast implants, where the implant is positioned above the pectoralis major muscle and directly beneath the subcutaneous tissue, has important implications for thoracic interventions. Unlike submuscular implants, pre-pectoral implants are more superficially located, making them more susceptible to direct trauma during ICC insertion (20). This anatomical positioning necessitates carefully modifying the standard ICC placement technique to minimise the risk of implant rupture, displacement, or capsular contracture. In this case, a superior adjustment of the insertion site by 1 cm and the use of a blunt dissection technique ensured successful drainage of the hemothorax while preserving implant integrity, highlighting the need for individualised procedural considerations in patients with breast reconstruction. In our case, the implant capsule was soft and non-adherent, with no signs of contracture or post-radiation fibrosis, which allowed sufficient mobility for manual displacement. It is important to emphasize that the proposed 1-cm superior shift is not a fixed recommendation but should be adapted to individual patient anatomy, including implant size, bra band size, and capsular characteristics.

The findings from this case and literature review stress the importance of adapting standard protocols for ICC placement in patients with breast implants. By incorporating modifications like repositioning the safety triangle, pre-procedural imaging, ultrasound guidance, and post-procedural imaging, clinicians can significantly enhance patient safety and reduce the risks associated with thoracic interventions. Further research and larger-scale studies are needed to validate these recommendations and establish comprehensive guidelines for managing ICC insertion in this patient population.

In the event of implant rupture caused by catheter placement, clinical management differs depending on the implant type. For saline implants, extravasated fluid is typically harmless and may be evacuated through gentle suction or gravity drainage. In contrast, silicone implant rupture requires prompt closure of any communication between the implant pocket and the pleural space to prevent silicone migration into the thoracic cavity. In such cases, relocation of the catheter insertion site may also be necessary. Definitive treatment often involves surgical removal or exchange of the implant once the patient is clinically stabilized (20,21).

This study combines a real-world case with an integrative review of the literature to address a clinically relevant but under-discussed procedural challenge. The case provides practical evidence of a simple anatomical adaptation that prevented a serious complication, and the derived recommendations are applicable in various thoracic procedures involving implant patients. Limitations include the single-case design and the lack of long-term follow-up beyond the immediate post-procedural phase. Additionally, while the rationale for the 1-cm shift is anatomically sound, it has not been prospectively validated in a larger cohort. Further studies are warranted to confirm these findings and standardize approaches across patient types.

Conclusions

ICC placement in patients with breast implants presents unique challenges due to the risk of implant rupture, pneumothorax, and aesthetic deformities. This case highlights the need for specific modifications to the standard ICC insertion technique, including pre-procedural imaging, superior repositioning of the triangle of safety, ultrasound-guided placement, and routine post-procedural imaging. Despite the lack of randomized controlled trials, existing literature supports adopting these techniques to minimize complications. Future research should specifically focus on developing standardized guidelines for ICC placement in breast implant patients to ensure safer, evidence-based practice.

Acknowledgments

None.

Footnote

Reporting Checklist: The authors have completed the CARE reporting checklist. Available at https://abs.amegroups.com/article/view/10.21037/abs-25-12/rc

Peer Review File: Available at https://abs.amegroups.com/article/view/10.21037/abs-25-12/prf

Funding: None.

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://abs.amegroups.com/article/view/10.21037/abs-25-12/coif). W.M.R. serves as an unpaid editorial board member of Annals of Breast Surgery from December 2023 to November 2025. The other authors have no conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. All procedures performed in this study were in accordance with the ethical standards of the institutional and/or national research committee(s) and with the Declaration of Helsinki and its subsequent amendments. Written informed consent was obtained from the patient for the publication of this case report and accompanying images. A copy of the written consent is available for review by the editorial office of this journal.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

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