The Surgeon Minute

Breast Revision – It’s More Complicated the Second Time Around

Breast Revision – It’s More Complicated the Second Time Around

There are women who walk around for months, even years, unhappy with the appearance of their breasts after their initial breast surgery. At some point, they may decide to move forward with  breast revision surgery to address their concerns. The truth is, breast surgery becomes much more complicated the second time around. In fact, some surgeons may turn away these patients due to the complex set of challenges associated with breast revision surgery. Others find it to be an exciting challenge, the king that brings relief to patients.

At 740 Park Plastic Surgery in New York City, Dr. Daniel Y. Maman embraces breast revision cases and the challenges that come with them. His training and expertise lie in reconstructive surgery after breast cancer, a field that translates well into the realm of cosmetic breast reconstruction. Many of the same principles and techniques used when reconstructing breasts after breast cancer are also used with great success in cosmetic breast revision cases.

The Driving Forces Behind Breast Revision Surgery

There are a great number of reasons why women may be interested in revising their initial breast surgery. It could be something as simple as the fact that they chose the wrong implant. “Oftentimes, choosing the wrong size implant leads to other problems down the road,” explains Maman.

If the original implant was too large, implant and nipple malposition may occur as a result. A heavy implant has a tendency to sink low on the chest wall, a condition referred to by surgeons as “bottoming out.” When this happens, the nipples appear to sit too high on the breast, making it difficult to cover the nipple in a bra or bikini top. Implant malposition after breast augmentation could also mean that the implant sits too wide on the chest wall.  

Reasons for Revisionary Breast Surgery:

  • Implant malposition: implant sits too low or too wide on the chest
  • Nipple malposition: nipple sits too high or too low on the breast
  • Capsular contracture: scar tissue causes implant to feel hard

Capsular contracture is a frequent issue. Whenever a breast implant is placed inside the chest, the body forms scar tissue around the implant. In most women, that scar tissue goes undetected – it remains thin and soft. In some women, however, this scar tissue forms abnormally. Over time it thickens, tightening around the implant. When this happens, the breasts may appear firm and feel hard, sometimes even painful, to the touch. 

Unknown Variables in Breast Revision Surgery

With initial breast surgery, the important decisions are all made ahead of time. The patient and surgeon decide together on the size of the implant, whether it will be placed above or below the muscle, and where the incision will be. With breast revision surgery, many of the decisions will depend on what the surgeon finds during surgery. When the initial breast surgery was done by another surgeon, Dr. Maman enters the operating room not knowing what exactly he will find.

Breast revision before and after.

“I oftentimes don’t know what technique was used; sometimes the operative report is not available. Sometimes the tissue has changed so significantly over time that I just don’t know what I’m going to find when I go in there,” he explains. “I think it’s important to tell patients, ‘Look, I’m going to do the best I can, to make you better, but really the decisions I’m going to make as to what the best treatment is, I’m going to have to make in the operating room when I look and see exactly what the right thing to do is.’”

Breast Revision & Reconstruction Techniques

In breast revision cases, Dr. Maman frequently utilizes a surgical mesh or scaffolding material to anchor the implant in its proper position. This is a technique he has a lot of experience with, as it is the same technique often used in breast cancer reconstruction patients after a mastectomy.

Surgical mesh used in breast revision surgery.

“Very typically in breast cancer reconstruction, because there is a complete absence of breast tissue, we have to position the implant on the chest wall, using some type of scaffold, whether it be a biologic scaffold like an acellular dermal matrix, or a synthetic scaffold or a synthetic mesh like a vicryl mesh or prolene mesh,” explains Maman. “The same is true in cosmetic breast surgery as it is in revisionary breast surgery. Oftentimes, because the implant has migrated or moved into an incorrect position, we have to secure that implant into place.”

Patient Satisfaction

After living with breast deformities for so long, his patients are thrilled to find a surgeon who is not only willing to help them, but has the experience and expertise necessary to successfully repair and improve their breasts. “What I find in my practice is that these patients tend to be some of my happiest patients,” concludes Dr. Maman. 

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