My biggest priority is to make this surgery the final one.
Revisional breast surgery may be necessary or desired after either cosmetic or reconstructive breast procedures. Since neither saline nor silicone implants last a lifetime, sometimes it is as simple as exchanging an old or ruptured implant. Conversely, the issue may be predicated on one or more problems. The most common reasons for breast revision surgery include, but are not limited to:
- Treating capsular contracture—a thickening of the internal scar around the implant, making the breast hard
- Correcting implant malposition
- Performing an augmentation years after a breast reduction
- Changing the size or shape of the original implant
- Changing the type of implant (saline/silicone)
- Changing a pocket from submuscular to subglandular (under/over the muscle)
- Performing a breast lift with new implants
- Improving reconstruction results with newer technology/techniques available
New technologies like Acellular Dermal Matrix material (see ADM section below), fat transfers, and novel surgical techniques have revolutionized revisional breast surgery and allowed for consistently successful outcomes.
Priorities
Revisional breast surgery has unique considerations that differ from an initial breast procedure. Comprehensive communication and extensive experience are critical elements to success. The concerns and goals must be clear and prioritized. Size? Position? Rippling? Palpability? It’s important that the goals of breast revision are both defined and realistic.
An effective strategy and a detailed plan for correcting each concern, can lead to a successful result. Anticipation on the part of the surgeon is key. Secondary breast revision may be unpredictable and can be analogous to the proverbial “Pandora’s box”. For this reason, the priority is to prepare for all possibilities, with a surgical plan that resembles a decision tree.
Hirmand Technique
The cornerstone in my approach is comprehensive due diligence. It is critical to have as much information about the previous surgery or surgeries before devising a final plan. The operative reports and photos, in addition to an indepth information gathering conversation, help craft the goals and options and to design a highly customized strategy. A good plan is predicated upon a thoughtful approach. The key to success is combining the appropriate tools and techniques, customized to the particular situation. Experience counts in revisional breast surgery.
Technique is dependent upon what is being revised.
Removal or replacement of implants for size or shape improvement is the most common revision. I correct size issues with extensive intra-operative sizing. It is not simply a matter of being bigger or smaller, but rather dimensional and proportional. The implant must have an appropriate profile and width in concert with the chest wall. This is highly individualized for each person.
Capsular Contraction (hardening of the scar tissue around the implant) and poor position of an implant may call for placing the implant in a new location. Changing the pocket to under the muscle from under gland or creating a new pocket under the muscle for the implant, when the implant is already under the muscle but there are issues, demands precision and meticulous dissection.
Removal of scar tissue is an exact and duteous process. If scar tissue is left behind another capsule can recur. The use of ADMs has been a tremendous novel tool in treating and preventing recurrent contracture, particularly in those who are prone to this condition.
In some situations, a new inframammary fold must be created by removing the implants and repositioning the location of the fold. The implant must be centered. If the implant rests too low on the chest, the nipples will turn up. A higher fold is re-created in these situations. Using ADMs has helped with support of the new fold. When the implant sits too high, the nipples point downward. Here, the fold will be lowered accordingly. The subtlety required for this procedure takes the dynamic (not just static) nature of the breasts into account.
A condition where the breasts are too close to each other is called Synmastia. To recreate cleavage through sutures alone is not enough support and the repair can tear and split. A combination of techniques, including use of Acellular Dermal Matrix, is used to create the new pocket and restore normal cleavage.
Treating ptosis (sagging) and shape issues by doing a lift or mastopexy, as part of the revision, often refines the result, bringing the breasts to a more youthful position.
A Note on ADMs - Acellular Dermal Matrices such as Strattice and Alloderm
A major advancement in breast surgery is the advent of ADM- a sheet of pure collagen matrix without any cellular component. It provides tissue to the breast for coverage and support when needed. Tissue grows into the collagen matrix of the ADM and it gets integrated over time.
ADMs sheets have become the standard of care for reconstruction but they are also extremely valuable for cosmetic revisions. They can correct rippling when there is not enough tissue, provide extra support for the breast, correct a divot or concavity, create and support a new inframammary fold, and most importantly can guard against a recurrence of capsular contracture. Understanding how to improve the foundation of the new breast using cutting edge technology such as ADM (like Strattice and Alloderm) has changed the course of revisional breast surgery.
Fat Grafting in Breast Revisions
Fat grafting is another technological advancement that has helped with breast revisions. Fat transfers can be used for revisions of both cosmetic and reconstructive situations. The efficacy of fat grafting has been well established but is highly technique dependent. Fat grafting can effectively improve contour, help correct rippling, concavities, and divots. It is also the best tool to recreate the normal chest to breast tear drop transition above the breast and in the cleavage area, to camouflage the round outline of the implant on the chest wall.
As part of normal aging, the chest wall tissue gets thinner. Fat grafting of the chest wall around an implant used for cosmetic purposes can help recreate a natural tear drop contour.
Surgical notes
Anesthesia: general
Length of surgery: variable, from 2-5 hours
Outpatient/inpatient: Out patient
Adjunct procedures: N/A
Recovery: 10 days