Breast Reconstruction Revision
Breast reconstruction revision patients come to me for revision of a previous breast reconstruction and often have a combination of issues that need to be resolved.
This is particularly true for patients who have had a one-sided reconstruction. As a general rule, if a patient has undergone a double mastectomy and reconstruction and has not been treated with radiation, the two breasts will behave similarly as time passes.
On the other hand, if the patient has undergone a one-sided mastectomy and reconstruction, the two breasts will behave differently as time passes, even if there was nearly perfect balance when the reconstruction was completed. I have helped patients with a wide variety of long-term issues after reconstruction. These issues include:
- Capsular contracture, a tightening of scar tissue around the implant.
- An abnormal shape to the reconstructed breast.
- An imbalance of size or position between the reconstructed and the natural breast.
- A harsh transition at the edge of the breast implant.
- Rippling or irregularity of the implant.
- Excess fullness in the upper portion of the reconstructed breast.
- Failure of a previous breast reconstruction.
Each of the issues that I have mentioned requires an approach that is based upon considerable skill and experience in techniques of reconstructive breast surgery. The good news is that a variety of advances in implant design and surgical technique increase the odds of achieving a good natural shape and balance between the two breasts.
These advances include acellular dermal matrix, autologous fat transfer, and form stable implants. A complete review of all of the approaches I have used to revise reconstructed breasts would require a description the size of a textbook.
Instead, I present here an overview of some of the more common strategies I use in this challenging field.
THE CONSULTATION FOR BREAST RECONSTRUCTION REVISION
The consultation about breast reconstruction revision is a sharing of information. From the patient I learn her general state of health, her priorities for the reconstruction, and her pattern of living and activity, since this may influence the choice of reconstructive methods.
I then make a careful list of the issues that I see in the reconstructed breast and discuss potential ways to improve the current situation. Since I have a referral practice, I see quite a few patients for revisional breast surgery in a given year. For these patients I emphasize a practical goal-oriented approach.
Above all, the patient must accept that although we can usually obtain a significant improvement, it is never possible to reach perfection. “Better, but not perfect” is a point that I emphasize repeatedly with my patients.
CORRECTING A RECONSTRUCTED BREAST THAT IS SMALLER AND HIGHER THAN THE NATURAL BREAST
This is a common pattern that I see in patients who are referred to be for revisional breast surgery after reconstruction. If the limiting factor is the tightness of the capsule around the reconstructive implant, but the skin of the breast is not tight, I can usually open up space for a larger implant by removing the capsule of scar tissue and placing acellular dermal matrix between the bottom edge of the pectoral muscle and the fold under the breast.
I will typically place a form stable implant and carry out fat transfer. I will modify the opposite natural breast so that it is lifted to a better position; if necessary I will reduce the volume of the breast to get the best possible match with the reconstructed side. If the skin of the reconstructed breast is too tight there are two options.
One possibility is to use a flap to bring in extra tissue. Another possibility is to place a tissue expand in order to provide more skin. External expansion may also be a possibility.
CORRECTING IRREGULARITIES OF THE RECONSTRUCTED BREAST
There are several possible causes of irregularity such as rippling in breasts that have been reconstructed with implants. In general, saline implants are more likely to show rippling and irregularity than silicone gel implants.
Sometimes there is a mismatch between the implant and the space where the implant sits. If the pocket is too small relative to the base dimension of the implant, this will cause the implant to fold and wrinkle. Too large a pocket can also allow the implant to shift out of alignment and develop wrinkles.
Patients who have very little structure over the implant also are more likely to show imperfection. I select a strategy for correction based upon my assessment of the most likely cause of the rippling, but I am prepared for extra measures in case I find other causes once I explore the pocket where the implant lies.
In general, I have found that form stable implants are less likely to wrinkle than other types of breast implants and silicone gel implants are less likely to ripple than saline implants. Form stable implants require a high degree of precision in terms of pocket design and positioning or they too can ripple.
Adjustment of the implant pocket, which may require acellular dermal matrix, is often an important step. It is also possible to provide extra structure for patients who have extremely thin coverage over their implants. This can be accomplished either with a fat transfer procedure or by placing a sheet of acellular dermal matrix over the implant.
CORRECTING EXCESSIVE FULLNESS IN THE UPPER PORTION OF A RECONSTRUCTED BREAST
Reconstructed breasts are more likely to be too full in their upper portions than natural breasts that have been augmented. There is less tissue to camouflage the upper border of the implant with mastectomy. Also the lower portion of the reconstructed breast can be tight, which pushes the implant toward the upper portion of the breast.
Fortunately several recent innovations in breast reconstruction surgery give us a better chance to restore a normal shape to reconstructed breasts so that there is a natural curve in the lower portion of the breast and an upper part of the breast that is not too full.
Form stable implants are made of highly cohesive silicone gel so that they maintain a natural shape. Just the conversion of a standard implant, particularly if it is high profile, to a form stable implant will do much to restore a pleasing breast shape.
Fat transfer can add volume to the lower portion of the reconstructed breast and also soften the transition at the upper edge of the implant.
Acellular dermal matrix can open up the space at the lower portion of the reconstructed breast so that a form stable implant can achieve optimum fullness.
CORRECTING FAILED BREAST RECONSTRUCTION
When a patient is referred to me with a failed breast reconstruction my first responsibility is to determine the cause of the failure. Once I understand the cause of the failure, I can devise a treatment plan that gives the best chance of success.
One cause of failure of an implant-based reconstruction is infection. If there is a skin-level infection of a reconstructed breast (cellulitis), this can usually be brought under control with antibiotics without the need to remove the implant. If there is an infection at the level of the implant, it is usually necessary to remove the implant to bring the infection under control. Once the infection is cleared it is usually possible to obtain a good quality reconstruction. There are many possible options including the use of flaps, the placement of tissue expanders and fat transfer.
Breakdown of the skin over an implant can also lead to failure of the breast reconstruction. Usually the breakdown occurs along an incision although it is possible to have this develop anywhere the skin is very thin. The likelihood of breakdown increases significantly if the area has been radiated. If the implant has not yet been exposed and there is no sign of infection, it is usually possible to salvage the situation. The specific strategy will be determined by the patient’s individual circumstances.
Surgical options include flaps, reinforcing the area with acellular dermal matrix, fat transfer, and the placement of an expander to take pressure off of an area of weakness. If the previous surgeon has had to remove the implant all is not lost. Sometimes it is desirable to bring in additional tissue with a flap. Often the disadvantages of a flap can be avoided with a series of fat transfers to restore quality and thickness to the breast skin. This process may be helped with a preliminary external skin-stretching device. Once I have prepared the breast skin in this manner I will place an expander and re-stretch the breast structures. When I have completed expansion, I will place an implant. Acellular dermal matrix frequently helps to provide additional internal protection of the implant.
Revisional breast surgery taxes the ingenuity of the surgeon and may require several operations, but the newer techniques have significantly increased the odds of success. Breast revision surgery can provide significant improvement in a patient’s quality of life.
Contact Dr. John Q. Cook
Dr. John Q. Cook is a renowned breast surgeon who has performed thousands of breast enhancement surgeries throughout his career. Dr. Cook is pleased to help revision breast reconstruction patients finally obtain the results they desire and deserve. If you are interested in learning more about revision breast surgery at Whole Beauty® Breast Institute, contact Dr. Cook today by calling 312-751-2112 or 847-446-7562 today.