Understanding BIA-ALCL

Breast Implant–Associated Anaplastic Large Cell Lymphoma (BIA-ALCL) is a rare type of non-Hodgkin T-cell lymphoma that arises in the fibrous scar capsule surrounding breast implants—most notably textured-surface devices. Although the overall risk is low, typically estimated at one to three cases per thousand textured implants, recognizing early warning signs and obtaining prompt, expert treatment are critical to achieving excellent outcomes. Dr. Carmen Kavali at Monarch Plastic Surgery & Skin Renewal Center in Sandy Springs, serving Buckhead and Atlanta, leads a comprehensive, multidisciplinary approach—combining detailed evaluation, advanced imaging, and definitive en bloc capsulectomy—to diagnose and treat BIA-ALCL while preserving patient safety and comfort.

BIA-ALCL is distinct from breast cancer. It is a lymphoma—a cancer of immune cells—occurring in the scar tissue (capsule) that forms around an implant. Most cases develop seven to ten years after implantation, though onset can range from two to twenty years. Patients with BIA-ALCL often present with a late seroma (fluid buildup), a palpable mass within the capsule, or regional lymph node enlargement. Early-stage disease confined to the fluid or capsule responds exceptionally well to surgical removal of the implant and capsule together (en bloc capsulectomy), with cure rates exceeding 90 percent when treated promptly.

• High Cure Rates: When diagnosed at Stage IA (disease limited to fluid around the implant) and managed with complete en bloc capsulectomy, five-year survival rates exceed 90 percent.
• Risk of Advanced Stage: Delays in diagnosis can allow the lymphoma to form solid masses, invade adjacent tissues, or spread to lymph nodes, requiring more extensive treatment.
• Minimally Invasive Diagnosis: Outpatient ultrasound and needle aspiration can often establish the diagnosis quickly, avoiding unnecessary delays.

At our Sandy Springs center, we prioritize early detection through patient education, routine follow-up, and ready access to imaging and pathology services.

While BIA-ALCL remains uncommon, certain factors increase risk:

• Textured Implants

  Over 90 percent of BIA-ALCL cases have occurred around macro-textured implants, in contrast to smooth implants, where the risk is exceedingly low.

• Duration Since Placement

  The median time to presentation is around eight years after implantation. Patients with implants older than two years should remain vigilant for new changes.

• Implant Indication

  Both cosmetic and reconstructive (post-mastectomy) implant recipients can develop BIA-ALCL.

• No Familial Link

  Cases arise sporadically; there is no established genetic or ethnic predisposition.

Key Takeaway: If you have textured implants and notice late-onset swelling, firmness, pain, or a breast lump—even many years after surgery—seek evaluation promptly.

Research suggests that bacterial biofilm forming on the textured implant surface may trigger chronic inflammation. This persistent immune activation can, over time, lead to malignant transformation of T-cells within the capsule. These malignant cells characteristically express the activation marker CD30 but lack ALK (an anaplastic lymphoma kinase), distinguishing BIA-ALCL from other lymphomas. Removing the entire capsule and implant en bloc (in one intact piece) is essential to eliminate both the tumor cells and associated inflammatory stimuli.

Patients with BIA-ALCL most commonly present with:

• Late Seroma: Painless or mildly uncomfortable swelling due to fluid accumulation, often without any trauma history.
• Palpable Mass: A firm lump in the breast or adjacent lymph nodes.
• Capsular Changes: Redness, firmness, or contour irregularity overlying the implant.
• Less Common Signs: Skin rash, breast pain, or systemic “B-symptoms” (fever, night sweats) in advanced cases.

Because these features can mimic benign post-operative seromas or infections, prompt ultrasound evaluation and fluid aspiration are critical to distinguish BIA-ALCL from other causes.

History & Physical Examination

Your surgeon will review your implant history—type, surface texture, placement date, and any revisions—and assess your symptoms, including timing and severity. Physical exam focuses on detecting fluid waves, palpable masses, skin changes, and lymphadenopathy.

Ultrasound

The first-line imaging modality for detecting peri-implant fluid collections larger than 20 mL or identifying capsular masses. It is rapid, non-invasive, and performed in-office.

MRI / PET-CT

If ultrasound findings are equivocal or if a solid mass is suspected, contrast-enhanced MRI can evaluate implant integrity and capsular thickness. PET-CT is reserved for staging confirmed disease, identifying nodal or distant spread.

Fluid Aspiration & Laboratory Analysis

Under ultrasound guidance, at least 50 mL of seroma fluid is aspirated and sent for:

• Cytology: Identifies large, atypical lymphoid cells.
• Flow Cytometry & Immunohistochemistry: Confirms CD30 positivity and ALK negativity.
• Microbiology: Rules out infection as a cause of fluid accumulation.

Multidisciplinary Review

Collaboration with hematology/oncology ensures accurate staging—based on the TNM system adapted for BIA-ALCL—and determines the need for additional therapies beyond surgery.

Stage IA (effusion only, no mass) is managed with en bloc capsulectomy and implant removal alone. For Stage IB(small capsular mass ≤ 2 cm), the same surgical approach generally suffices. Disease presenting as larger masses or with nodal involvement (Stages IIA and above) often requires adjuvant chemotherapy or radiation after complete surgical excision. Early-stage patients typically do not require systemic therapy, underscoring the importance of early detection.

• Capsulectomy Technique
  • En Bloc Capsulectomy: Preferred for localized disease—removes implant and intact capsule to prevent tumor spillage.
  • Total Capsulectomy: Piece-by-piece removal when anatomy or adhesion patterns prevent en bloc excision, ensuring all affected tissue is removed.
• Incision Selection
  • Inframammary Fold: Provides wide access with a well-hidden scar.
  • Periareolar or Transaxillary: Considered for patients with existing scars or specific cosmetic needs, though may limit visualization.
• Reconstruction Strategy
  • Delayed Reconstruction: Standard approach—reassess healing and pathology before restoring volume.
  • Immediate Fat Transfer: In select Stage IA patients, autologous fat grafting offers natural contour restoration without re-implantation.
• Adjuvant Therapy
  • Surveillance Only: Early-stage (capsule-confined) disease often requires no further treatment.
  • Chemotherapy / Radiation: Recommended for masses greater than 2 cm, nodal disease, or incomplete excision.

• Anesthesia & Marking

  Performed under general anesthesia. Pre-operative markings delineate prior incisions and capsule boundaries with the patient upright.

• Incision & Initial Dissection

  The surgeon reopens the implant scar—most commonly inframammary—and carefully dissects down to the capsule, preserving its integrity.

• Capsule Mobilization

  Using meticulous technique, the implant and capsule are freed circumferentially, avoiding any tears that could spill malignant cells.

• Specimen Removal

  The intact implant-capsule unit is delivered en bloc. This specimen is sent in its entirety to pathology to confirm clear margins.

• Pocket Irrigation & Inspection

  After removal, the surgical pocket is irrigated with antibiotic solution and inspected for any residual diseased tissue.

• Closure & Support

  Multilayer absorbable sutures close the deeper tissue and skin. Steri-strips reinforce the incisions, and a supportive surgical bra minimizes movement and swelling.

Procedure Time: 1.5–2.5 hours
Setting: Accredited outpatient surgical suite—same-day discharge with responsible escort

• Medical Clearance: Routine labs (CBC, CMP), EKG if age > 40 or cardiac risk factors.
• Medication Review: Discontinue anticoagulants per protocol; optimize nutritional status and hydration.
• Lifestyle Adjustments: Cease smoking/vaping at least four weeks before and after surgery; limit alcohol intake.
• Home Setup: Arrange for post-op support, pillows for elevation, ice packs, easy-prepare meals, and entertainment.

• Days 1–3: Manage discomfort with oral analgesics and cold compresses; rest upright to reduce swelling.
• Weeks 1–2: One-week follow-up to assess healing and remove any drains; continue wearing a soft support bra and begin gentle ambulation.
• Weeks 3–6: Swelling subsides; initiate scar care with silicone gels or sheets after incisions heal; resume desk work while deferring strenuous chest exercise until week six.
• Months 2–6: Final breast contour stabilizes; follow-up imaging or lab tests as recommended by oncology; plan delayed reconstruction if chosen.

Strict adherence to Dr. Kavali’s post-operative protocol ensures optimal healing, minimizes complications, and supports oncologic safety.

Benefits:

• Definitive removal of diseased tissue, leading to high cure rates in early-stage disease
• Opportunity for aesthetic restoration, whether via delayed implants or immediate fat grafting
• Peace of mind from eliminating the source of lymphoma and associated anxiety

Risks:

• Bleeding or hematoma—rare and usually managed with drainage
• Infection—minimized with sterile technique and peri-operative antibiotics
• Scarring—controlled with meticulous closure and sun protection
• Anesthesia risks—standard for any general anesthesia procedure
• Potential persistent systemic symptoms if multifactorial beyond BIA-ALCL

Dr. Kavali will review all risks during consultation, ensuring fully informed decision-making.

When seeking BIA-ALCL evaluation and treatment in Sandy Springs, Buckhead, or Atlanta, look for:

• Board Certification: American Board of Plastic Surgery
• Oncologic Collaboration: Proven experience in multidisciplinary lymphoma management
• Accredited Facility: AAAASF or Joint Commission accreditation ensures safety standards
• Case Experience: Demonstrated expertise in en bloc capsulectomy and reconstruction
• Comprehensive Support: Access to integrative wellness services and long-term follow-up

Dr. Carmen Kavali’s specialized training and our state-of-the-art surgical suite deliver unparalleled care, combining oncologic rigor with aesthetic excellence.

If you notice late-onset breast swelling, firmness, or a mass after textured implant placement, early evaluation is vital. Contact Monarch Plastic Surgery & Skin Renewal Center to schedule your BIA-ALCL assessment:

• Call: 404.250.3333
• Email: info(at)drkavali(dotted)com
• Visit: 6045 Barfield Rd, Suite 100, Atlanta, GA 30328
• Online: Request a Consultation

Dr. Kavali will guide you through diagnosis, definitive treatment, and any reconstruction—helping you reclaim health, confidence, and peace of mind.