Breast revision surgeries are some of the most challenging procedures in plastic surgery due to the delicate nature of the female breast and the fact that it is necessary to achieve symmetry between the two breasts. For this reason, it is often necessary to perform revision breast surgery to correct not only deformities from previous cosmetic procedures, but also deformities resulting from breast cancer surgery such as mastectomies. Fortunately, there are cutting edge techniques available today that offer women and their plastic surgeons a wide range of choices for breast reconstruction.
Reconstruction after breast cancer surgery.
Breast Cancer is the most common form of cancer among women of all ages and races. The mortality rate, however, due to early screening and advanced treatment options has been decreasing about 2.2% per year over the last decade. This means that women today can look forward to many healthy years after being diagnosed with breast cancer and many are considering the option of immediate or delayed breast reconstruction following a mastectomy. We find that it is very important for patients to have access to a team approach. Meaning that, before considering surgery, they should meet with their breast surgeon, their oncologist, as well as their plastic and reconstructive surgeon to discuss all the options available for breast reconstruction following mastectomy.
Today women have many options for breast reconstruction. They can have their breast reconstructed with a breast implant that can be either saline or silicone. Today there are many different types of silicone implants to choose from such as the cohesive silicone gels, also known as gummy bears, which offer a very natural feel and look to the reconstructed breast. Many women, however, opt to have breast reconstruction with autologous tissue meaning that the breast is reconstructed with their own tissue. The tissue is usually harvested from the abdomen also known as a TRAM flap or from the back, known as Latissimus Dorsi flap. The tram flaps, which are based off the rectus abdominis muscle of the abdomen, can also be done in a muscle sparing fashion or a free flap to preserve the function of the abdomen. All of these options with autologis tissue can offer a very natural looking breast with good symmetry which is why many women are choosing to have this type of reconstruction immediately following a breast mastectomy.
Fig 1A Mastectomy Site Fig 2A Reconstructed Breast
1B Right Rectus Muscle 2B Scar around the new belly button
1C – Left rectus muscle used to 2C Abdominal scar from harvesting
reconstruct the right breast in this case the flap (similar to the tummy
1D Island of skin and fat used in shaping tuck scar)
the new breast
Congenital Breast Deformities.
All women have breasts that are different in some way. No two breasts are completely identical. Some women, however, have congenital deformities which significantly alter the appearance of one or both breasts. One of the most common is the tubular breast deformity where the breast is very narrow and constricted at the base and the breast tissue is projected in a cone shape, thus the name tubular breast deformity. Specialized techniques and breast reconstruction can be used to widen the base of the breast and give the breast a much more natural shape and projection using an implant which can be either a saline or silicone implant. At the time of your consultation with Dr. Polynice, he will discuss with you all of the different sizes, types and shapes of implants that can be used to achieve the most natural look possible.
Revision Breast Surgery following previous cosmetic breast surgery or breast reduction.
Many women who have had breast surgery in the past, whether it be a breast lift or breast reduction, may be unhappy or dissatisfied with the results. Older techniques of breast reduction and breast lift left a very noticeable scar sometimes shaped like an anchor. This scar would sometimes become hypertrophic and be quite visible along the anterior chest. For this reason we have developed cutting edge techniques in breast sculpting and breast shaping that allow us to achieve excellent results as far as the projection and contour of the breast and also minimize the residual scars. All of these latest techniques can be discussed with you in detail at the time of your consultation with Dr. Polynice.
Bottoming out is a complication which may occur following breast augmentation if the breast implant falls to a lower position in the implant pocket due to a shift in the inframammary fold. When this occurs, the implant will appear to sit much lower on the chest while the nipple position will appear much higher up on the implant.
Bottoming out can occur for a variety of reasons. It may occur in very thin patients who have very little soft tissue covering the implant so that the weight of the implant causes the skin to stretch and the pocket to widen. This then causes the implant to shift and sit too low in the implant pocket.
Correcting bottoming out can be challenging. Essentially the inframammary fold must be readjusted and lifted. This can be achieved with suture techniques or by reinforcing the inframammary fold with acellular dermal matrix products like Strattice. These products have proven very effective in correcting and controlling bottoming out.
Dr. Alain Polynice of the Williams Center for Plastic Surgery performs breast revision procedures to correct bottoming out at the New England Laser & Cosmetic Surgery Center in Latham, New York. General anesthesia or MAC anesthesia may be used and surgical times average 1.5 hours. Patients can expect a recovery period of about one week, after which time work and most other normal activities can be resumed. Dissolvable stitches are typically used and do not need to be removed. Patients will need to postpone more strenuous activities for about four to six weeks.
click here to view before and after photographs.
Breast Reconstruction following Mastectomy
While breast cancer is the most common form of cancer in women, the mortality rates have dramatically decreased in recent years, allowing many women to live long, healthy lives following diagnosis. Today, many women undergoing lumpectomy or mastectomy for breast cancer opt for immediate or delayed breast reconstruction.
Breast reconstruction is a procedure which reconstructs a missing breast using the patient’s own tissues or a tissue expander followed by a permanent implant. Candidates include women who have had either a lumpectomy or mastectomy for breast cancer. Breast reconstruction may be performed at the time of mastectomy or months or years later. Most women require additional touch-up procedures to further contour or shape the breast and to reconstruct the nipple.
Dr. Alain Polynice MD typically performs breast reconstruction procedures at the Williams Center of Latham, New York, or at Albany Medical Center in Albany, New York. General anesthesia is used and, depending on the particular technique, the surgery may take anywhere from two to six hours to complete.
There are many different techniques which may be used for breast reconstruction. Many women today are opting for breast reconstruction using their own tissue. Tissue may be harvested as flaps from the patient’s abdomen or back which is then used to create a very natural looking breast. Alternately, saline or silicone gel implants may be used to reconstruct the breast. Breast implants typically require the use of a tissue expander to stretch the tissue in order to provide sufficient coverage for the implant. Tissue expanders are left in place for several months and are gradually filled over time to expand the skin. This is then followed by placement of the implant.
Recovery following breast reconstruction typically takes two to four weeks, after which time patients can generally return to work and other normal activities. Exercise and more strenuous activities should be postponed for four weeks. As with any surgical procedure, some bruising and swelling may result. All sutures are internal so stitches do not need to be removed. Risks are generally rare but may include bleeding, infection and asymmetry.
Capsular contracture is one complication that can occur after breast augmentation. It is not a very common complication, occurring in just 5% to 8% of breast augmentation patients, but it can be a troublesome one. Capsular contracture is slightly more likely to occur with silicone implants; however, placing silicone implants in the subpectoral location under the muscle does reduce the risk.
When any foreign object such as a breast implant is placed inside of the body, it is the body’s natural response to form a capsule or lining of fibrous tissue around it. Capsular contracture occurs when this capsule tightens and squeezes the implant. Capsular contracture can occur in varying degrees which are ranked from grades 1 through 4. With grade 1 capsular contracture, the breast is essentially normal. With grade 2, the breast appears essentially normal to the patient but the surgeon may be able to feel the capsule hardening. With grade 3, both the patient and surgeon can feel the capsule hardening and the patient may be beginning to experience some symptoms of discomfort. Grade 4 is a very severe contracture with a very hardened capsule causing discomfort as well as a change in the shape and displacement of the implant.
There are some steps which can be taken to decrease the risk of capsular contracture. Proper implant selection and implant placement in the subpectoral pocket can lessen the risk. Breast massage has been shown to be very effective in preventing the formation of thickened capsule and this, ideally, should begin early on in the first week or two after surgery. Oral vitamin E has also shown to be helpful, as well as the asthma medication Singulair though this medication has not been studied extensively and may have side effects such as liver problems.
When capsular contracture does occur, treatment may become necessary. Ultrasound treatments have shown some effectiveness in improving capsular contracture; however, surgical intervention is sometimes necessary. Dr. Alain Polynice MD of the Williams Center for Plastic Surgery performs breast revision surgery to correct capsular contracture at the New England Laser & Cosmetic Surgery Center in Latham, New York. The surgery may take anywhere from one to four hours to complete depending on the severity of the problem and is commonly performed with either general anesthesia or MAC anesthesia. During the procedure, the incision is opened up and either a capsulotomy or complete capsulotomy may be performed. With capsulotomy, the capsule is opened by scoring it which allows the implant to fall back into its natural position. With complete capsulotomy, the capsule is completely removed and the implant is usually replaced.
Recovery following breast revision for capsular contracture generally takes seven to ten days and most patients are able to return to work within one to two weeks.
Implant malposition refers to implants that are asymmetrical. Essentially the implants do not sit well within the implant pockets and may have shifted medially (toward the middle) as in the case of symmastia, laterally (to the sides) or superiorly.
Dr. Alain Polynice MD of the Williams Center for Plastic Surgery performs breast revision surgery to correct implant malposition at the New England Laser & Cosmetic Surgery Center in Latham, New York. General or MAC anesthesia is commonly used and surgical times may be anywhere from one to four hours depending upon the severity of the problem. The surgery may be performed through the peri-areolar incision or the IMF incision (inframammary fold). Through this incision, the pocket is reopened, the implant is removed, and the necessary adjustments are then made. This may involve widening the pocket if necessary, removing thickened capsule tissue if that is causing the malposition, or readjusting the pocket inferiorly. Correcting pocket malposition can be accomplished very effectively with acellular dermal matrix products like Strattice which force the pocket on either side, medially, inferiorly and laterally, thus recreating a new stable environment for the implant to remain in place.
Recovery following breast revision for implant malposition generally takes seven to ten days. Stitches are dissolvable and do not need to be removed. Patients are typically able to return to work and other normal activities within one to two weeks.
What happens when an implant ruptures? If the implant is saline, the sterile saline solution will leak out, causing the breast to deflate or flatten. This is generally noticeable to the patient so she knows to seek medical attention right away. If the implant is silicone, however, the patient may experience few or even no symptoms because the modern cohesive gel implants used today are designed so that the gel does not leak. As such, there is often no obvious flattening of the breast that occurs, though patients may experience some degree of pain, tingling or redness. In some cases, a ruptured silicone gel implant may become more palpable or hard and indurated, causing a change in the breast size. If a silicone implant ruptures and is not corrected, capsular contracture may result. This is when the body forms very thick scar tissue around the implant which may tighten and squeeze the implant. Any of these symptoms should prompt an immediate checkup with your plastic surgeon. A ruptured silicone implant can be diagnosed with either ultrasound or more commonly MRI.
Dr. Alain Polynice MD of the Williams Center for Plastic Surgery performs breast revision surgery to correct implant rupture at the New England Laser & Cosmetic Surgery Center in Latham, New York. The surgery is commonly performed with either general anesthesia or MAC anesthesia and may take one to three hours to complete. During surgery, the incision beneath the breast or around the areola is reopened and the implant is removed. If capsular contracture is present, the thickened capsule is removed. The pocket is then adjusted and a new implant is placed. If an older silicone implant involving softer silicone gel is involved, any free silicone material that has leaked outside of the shell of the implant but is still contained within the capsule must be completely cleaned out as well.
The recovery period following breast revision for breast implant rupture takes approximately seven to ten days, after which time patients can usually return to work and other normal activities. Stitches are dissolvable and do not need to be removed. Exercise and more strenuous activities should be postponed for about four weeks. The risks of breast revision surgery are minimal, but there are potential risks just as with any surgery. However, the risk of leaving a ruptured implant in place is much greater.
Rippling of the Implant
Rippling of the breast is a complication which may occur following breast augmentation. This is more likely to occur with saline implants and when the implants are placed above the muscle so that there is only skin and breast tissue covering the implant. Rippling is actually very common in women with very little breast tissue who have their implants placed above the muscle. Any patient considering saline implants should be counseled about the risk of rippling.
Rippling may also be affected by the texture of the implant. Some implants have a smooth surface and others have a textured surface. Textured implants can have a thicker surface which may be more likely to cause rippling. If rippling does occur, switching to a smooth implant may be the solution. Also, because silicone implants are much less likely to cause rippling, switching from saline to silicone implants can help. Another solution may be to change the location of the implant from the subglandular position (above the chest muscle) to the subpectoral position (under the muscle). In this position there is more soft tissue as well as the muscle covering the implant so therefore rippling is insignificant and not noticeable.
Dr. Alain Polynice MD of the Williams Center for Plastic Surgery performs breast revision surgery to correct breast implant rippling at the New England Laser & Cosmetic Surgery Center in Latham, New York. General or MAC anesthesia may be used and surgical times average one to four hours. During surgery, the old incision may be opened or a new incision may be made around the areola or under the breast. The implant is then removed and exchanged, typically in a new pocket under the muscle. Dr. Polynice may use acellular dermal matrix products like Strattice which have proven very effective in treating implant rippling. Made form pigskin, this product has been used extensively in breast reconstruction, hernia repair and in burn patients. It is a very effective tool in breast revision for providing extra coverage and support for the implant and for treating rippling.
Recovery following breast revision for implant rippling takes approximately seven to ten days. The stitches do not need to be removed because they are dissolvable. Patients are typically able to return to work and other normal activities after one to two weeks.
Symmastia is one complication that can occur following breast augmentation. Unfortunately, it is a very complex problem and one of the most difficult to fix in plastic surgery. Symmastia is often referred to as “unibreast” or “uniboob” because it occurs when the breast implants meet in the middle. Essentially, there is one big pocket for the implants instead of two separate pockets. This is because the medial aspect, or the area of the breast overlying the sternum, has been over-dissected, thus creating one anatomical pocket.
Symmastia is a very difficult complication to correct because the skin overlying the sternum must be reattached back down to the sternum and this can be technically challenging. If the breast implants were originally placed over the muscle in the subglandular position, then one solution would be to change the pocket to the under the muscle or sub-pectoral position. An acellular dermal matrix product like Strattice may also be used in the medial or middle aspect of the pocket to recreate two separate pockets and prevent the implants from touching in the middle.
Dr. Alain Polynice MD of the Williams Center for Plastic Surgery performs breast revision surgery to correct symmastia at the New England Laser & Cosmetic Surgery Center in Latham, New York. Again, this is a very complex problem to fix surgically and it may take anywhere from two to five hours to complete. General anesthesia is commonly used. The recovery typically takes one to two weeks and patients are usually able to return to work after two weeks. Stitches are dissolvable and do not require removal. Exercise and strenuous activities should be postponed for four to six weeks.
Tubular Breast Deformity
This is a congenital breast deformity that occurs when breast development fails to proceed normally during puberty. The exact cause is unknown but the result is a breast that typically includes very enlarged puffy areolas, a very wide space between the breast and a very tight base at the level of the inframammary fold. The breast tissue seems to be protruding or projecting into the areola thereby causing the very large puffy appearance. It could be from a very mild to a very tight, severe form. It is not uncommon for a woman to have this deformity only on one side. The condition is relatively rare, occurring in about 1-5% of breast augmentation patients, but in patients younger than 18 years old having breast augmentation more than 16% are having it because of a congenital tubal breast deformity.
The procedure for correcting a tubular breast deformity does involve placing implants. It is more complicated than a straightforward breast augmentation because of the narrow, tight base of tubular breasts. The implants sometimes need to be used after placing a tissue expander in order to create more tissue, but typically it is possible to place the implants under the breasts by scoring and widening the base and releasing the tight attachments that are causing the deformity. The implants can be placed either under the muscle or under the breast tissue but in severe cases of tubular breast deformity it is sometimes preferable to place the implants under the breasts itself. The surgery itself can take anywhere from two to three hours. It is done under local anesthesia with sedation but more severe cases may need to be done under general anesthesia. The incision is typically in the fold under the breast but it can also be done with an incision around the areola. Recovery time is about two weeks before most people can resume their normal activities and four weeks before patients can do strenuous exercising such as weight lifting or exercising at the gym. All sutures are internal and dissolve on their own and do not need to be removed. Most patients do require drainage tubes to drain off all the excess swelling fluid; these stay in typically six to seven days.