Top Three Reasons for Revision Breast Reconstruction

Mastectomy, which removes the entirety of breast tissue in one or both breasts, is undoubtedly a major surgery, and it’s not always easy to predict how each woman’s body will heal after the physical trauma of this procedure and subsequent reconstruction. For a variety of reasons, it is not uncommon for patients to undergo multiple surgeries before she is completely satisfied with the look of her new breasts. Here, we address the most common cosmetic issues that may arise with prosthetic reconstruction (direct-to-implant or expander/implant) and explain revision procedures that Dr. Kim often performs to achieve the patient’s desired look.

1. CAPSULAR CONTRACTURE – The breast becomes tight

As it is necessary to completely remove all breast tissue, the skin flap that is left after mastectomy is very thin and much less cushioned than before. In the case of expander/implant breast reconstruction this may lead to cosmetic issues such as capsular contracture and rippling. Capsular contracture refers to tightening that may occur around a breast implant as scar tissue forms and creates a breast “capsule.” This capsule forms in all patients with implants (even augmentation cases) and is usually unnoticeable, but in some cases, it may become very tight and lead to the implant looking constricted and unnatural. When this occurs, Dr. Kim may perform a capsulotomy and capsulectomy, in which he releases and removes scar tissue to loosen the breast capsule. He may combine this procedure with fat injections and acellular dermal matrix (ADM) to further cushion the breast and prevent recapsularization.

52-year old woman with history of right mastectomy and left augmentation, following right revision with ADM, capsulotomy, fat injections, and left implant downsize with ADM

Some cancers may necessitate the use of radiation therapy, which greatly increases the risk of capsular contracture. In these cases, Dr. Kim may recommend an autologous reconstruction, as opposed to implant reconstruction, since natural tissue does not tighten in the same way when exposed to radiation. Sometimes, however, an autologous reconstruction is not possible, in which case Dr. Kim uses a combination of the aforementioned methods in order to loosen the breast capsule after therapy is completed.

2. RIPPLING – The implants have caused breast skin to wrinkle

As explained earlier, the mastectomy skin flap is relatively thin, so imperfections such as ripples and divots may be apparent when this skin is stretched over an implant. In these cases, autologous fat grafting is very useful to smooth trouble areas. During the fat grafting procedure, fat cells are taken via liposuction from an area of the patients’ body that has extra tissue (usually the thighs or abdomen) before being filtered and reinjected into the breast. Unlike liposuction without fat transfer, it is extremely vital that the fat cells are harvested by a technique that does not destroy them in the process, as living cells are necessary for a successful graft.

The benefits of utilizing the patient’s own fat cells are numerous, the greatest being that the fat is already known to be entirely compatible with the body so the risk of allergic reaction is virtually zero. Studies have shown that about 50% of the injected fat is reabsorbed by the body over time, so it is not uncommon for the surgeon to slightly overcorrect when filling in imperfections. Reabsorption varies woman to woman, so it may be necessary to complete multiple rounds of fat injections before the desired contour is achieved. A more detailed explanation of fat injections is available here.

Breast Reconstruction Revision
Bilateral nipple sparing mastectomies followed by 2-stage expander/implant submuscular breast reconstruction, 640 cc textured shaped silicone gel implants, 8 months post op

3. ASYMMETRY – One or both implants shift within the breast capsule, creating a lopsided appearance

It is difficult to predict how the breast will heal after mastectomy, and some cases may prove challenging to achieve symmetry. Sometimes, one breast contracts more than the other, leaving one implant malpositioned in relation to the other. Additionally, radiation to one breast often leads to capsular contracture in that breast alone, leaving the radiated breast high and tight (as seen in the case photos below).

33-year old woman with history of bilateral expander/implant reconstruction and right radiation, following right capsulotomy, left revision with ADM, and bilateral fat injections
55-year old woman with history of left expander/implant reconstruction with radiation and left augmentation, following left revision with ADM, capsulotomy, and fat injections as well as right implant downsize with ADM
Breast Reconstruction Revision
History of submuscular breast reconstruction and asymmetry. Left breast revision with the use of suture mesh, 4 months post op

In cases of asymmetry, Dr. Kim uses a sheet of acellular dermal matrix (ADM) to serve as an “internal brassiere” that provides support for the implant. ADM is made from natural human tissue, particularly the collagen layer of skin that is responsible for its strength and flexibility. After cutting a sheet of ADM to the right size and shape, Dr. Kim uses absorbable sutures to fasten it in place, creating a hammock support for the implant. Since ADM is bioresorbable, it is eventually replaced by the patient’s own collagen and completely integrated into the patient’s tissue.

Most often, Dr. Kim uses ADM to adjust the inframammary fold for vertical symmetry, but he may also use it on either side of the breast to correct lateral (toward the side) or medial (toward the middle) displacement of the implant. ADM gives the surgeon control over the contour of the reconstructed breast and has proven to be a reliable tool in managing some of the most challenging problems in implant-based breast reconstruction. The video galley contains multiple videos of Dr. Kim performing revision surgeries with ADM – watch here.

39-year old woman with history of right expander/implant reconstruction (at outside institution), following right revision with ADM to correct symmastia (medial displacement of implant) and left expander/implant reconstruction
Breast Reconstruction Revision
History of submuscular bilateral breast reconstruction. Bilateral implant exchange, 615 cc textured shaped silicone gel implants, 3 weeks post op

Breast reconstruction is a highly variable art, and as such, the need for additional procedures is evaluated on a case-by-case basis. Patients must be aware that breast reconstruction does not come without risks and does not always go according to plan, but Dr. Kim will work with each individual patient to achieve a reconstruction that she can be proud of.