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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.

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.

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).

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.

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.

Breast Revision FAQs

Am I a candidate for breast revision?

Breast revision involves removal of breast implants while maintaining a natural, graceful body profile. Women choose the procedure for a variety of reasons, ranging from aesthetic to medical. Sometimes it is a matter of preference: a patient simply does not like the look or feel of implants, or the goals she was hoping to achieve were not met. Sometimes patients have health conditions, such as autoimmune diseases, that may be aggravated by the presence of implants. In other cases, the initial surgery may have gone wrong, or there were side effects that were not sufficiently anticipated by the surgeon. For example, implants may have lost integrity, drifted or even damaged surrounding tissue.

Is breast revision complicated?

Breast revision is major surgery, and a decision that should be made after reviewing the benefits, risks and options. The procedure will be more complicated than the original placement of an implant, as scar tissue forms after most surgical procedures.

When implants are removed, the pocket that held the implant must be refilled with your natural tissue to restore an aesthetically pleasing profile. This involves a procedure that is similar to breast lift. When large implants are removed, the skin may have a stretched look; in addition, the breasts may appear to sag or have a deflated appearance. Dr. Kim is skilled in reshaping and lifting your breast tissue to ensure your look is as natural as before your initial surgery. Efficient tightening of the skin and precise placement of tissue to refill the area are critical to ensuring your satisfaction with the final result.

What if I want a different type of implant?

This is very common. Breast revision patients often choose a replacement implant that is a different size or made from different material. Some women decide that saline implants feel less natural than they expected, and swap saline for a silicone gel variety. Other women may have health or safety concerns about silicone gel implants, and choose saline for replacement breast implants. If you choose smaller implants, the area surrounding the new implant will need to be tightened, and skin may need to be lifted. An increase in breast size will require the surgical creation of a larger pocket to accommodate the bigger implant.

What is recovery like?

If your breast revision surgery involved the removal of scar tissue, such as with capsular contracture, you may feel some discomfort, which will be managed with prescribed medication. Beyond that, your recovery will be very similar to that of your initial surgery. You will again experience soreness and swelling, and will need to limit activities for several days. It will actually take several months for the swelling to disappear.

What should I expect with breast revision surgery after breast cancer?

If your revision involves reconstruction after cancer, you will typically require several surgeries, over a period of six months to a year. The series of procedures may be delayed at times if you are still receiving cancer treatments. Depending on your preferences, you may shorten the process by delaying or forgoing certain elements of breast reconstruction. Typically, the full process includes surgery to create a new breast, followed three months later by surgery to adjust the breast for appearance, balance and proportion. This step may need to be repeated once or twice, at three-month intervals. The final step involves surgery to add a nipple and areola to the breast. This usually occurs two or three months after the final adjustment procedure.