Revising Previous Breast Reconstruction

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Information

PROCEDURE

Revision or Correction of previous breast reconstruction surgery, performed elsewhere

  • To correct complications or poor outcomes after previous breast reconstruction surgery.
  • Most commonly this surgery is required after previous breast reconstruction with implants.
  • Surgery may be required to improve shape or contour, correct for muscle animation or capsular contracture, and to address issues with pain.
  • This is complex surgery and Dr Campbell-Lloyd is one of very few surgeons who will offer revision procedures to women whose reconstruction was started by another surgeon. We may not be able to fully correct for what has been done previously, but in most cases improvements are possible.

COSTS:
Plastic surgeon’s fee: from $7,990

Total approximate cost (insured patient where item number applicable): from $ TBC

Note: Dr Campbell-Lloyd is unable to offer revision surgery to uninsured patients. We recommend that any patient considering revision has suitable health insurance coverage.

Associated item number(s): 45551/45554 (capsulectomy, implant exchange), 45534/45535 (fat transfer)

Level of health insurance cover recommended: Silver tier

May be performed in conjunction with: DIEP flap surgery

LENGTH OF PROCEDURE/HOSPITAL STAY:
2.5-4.5 hours

Day surgery for most patients, unless converting from implant-based reconstruction to DIEP flap.

Breast reconstruction with implants is the most common form of breast reconstruction after mastectomy. It is frequently performed by general surgeons on their own, as well as in conjunction with plastic surgeons. As a result, a number of techniques may be used, and the outcomes can be very variable.

Whilst implant-based reconstruction can be successful for some women, the majority of women with an implant based reconstruction will need revision procedures performed within 5-10 years, if not sooner. Most women with an implant-based reconstruction will have revision procedures performed by the original reconstructive surgeon.

For women who either cannot, or prefer not to be treated by their original surgeon, it can be enormously challenging to access the necessary revision surgery.

A number of issues frequently arise after implant-based reconstruction:

  • poor contour due to irregularity of the breast skin after the mastectomy, impalnt rippling, or the use of certain "meshes"
  • loss of definition of the crease under the breast
  • tight, shiny or stretched skin
  • pain associated with implants
  • movement of the implants due to contraction of the chest muscle ("implant animation")
  • and incorrect implant sizing (either too narrow or too wide)

Most of these issues can be corrected to some extent. We cannot restore the breast to what it was prior to mastectomy, but we can make substantial improvements.

All breast implants are associated with a range of complications, the risk of which increases over time. All breast implants will require removal or replacement at some point in the future, including after revision procedures. The only way to avoid a lifetime of revision surgery is to convert an implant-based reconstruction to an autologous reconstruction.

Key Features

"Plane change"

Whilst the use of pre-pectoral techniques in breast reconstruction are increasing, the vast majority of implant-based reconstruction is still performed by placing the implant under the chest muscles.

Two of the main reasons patients seek revision surgery with Dr Campbell-Lloyd are to address capsular contracture and its consequences, and to undo the functional limitations created by cutting the Pectoralis major muscle and placing an implant in an under-the-muscle or "dual-plane" pocket. Dr Campbell-Lloyd believes that the only way to achieve durable results after implant revision is by ensuring that a new implant is placed in a totally new pocket, after performing a complete capsulectomy.

Attempts to modify existing pockets are associated with the early recurrence of complications. In the past, and even now, many surgeons perform revision surgery by simply releasing the contracted scar tissue (capsulotomy) to allow it to expand, or tightening the capsule where necessary for support (using sutures or "heat shrinkage). These techniques fail to manage the basic processes which result in capsular contracture.

Dr Campbell-Lloyd recommends a complete capsulectomy, and conversion to a pre-pectoral pocket in most cases however this may not always be possible in reconstructive cases (unlike in cosmetic revision surgery). There are circumstances where partial retention of the old capsule is necessary for safety or technical reasons.

Removal of permanent synthetic "mesh"

Many surgeons choose to use a variety of meshes to support the original reconstruction. Meshes may be "dissolving", or they may be permanent synthetic meshes. Dr Campbell-Lloyd never uses the permanent synthetic meshes in his reconstruction, but they remain very common. Synthetic meshes can create an unpleasant feeling to the breast skin, distortion of the breast shape, or they create concern for patients who prefer not to have these materials in their bodies. The most commonly used synthetic mesh is a product called Ti-Loop, which is a woven polypropylene. Scar tissue grows into this mesh whcih may result in a feeling of stiffness and rigidity for some women.

The use of dissolving, temporary meshes are less likely to be associated with long term problems. Dr Campbell-Lloyd does recommend the use of P4HB mesh in some cases where additional support for a breast implant is required.

Pectoralis major muscle repair

Dr Campbell-Lloyd will always repair the Pectoralis major muscle following capsulectomy where an implant has been moved out of an under-the-muscle pocket. Restoring the muscle to its natural position is a key step in creating a stable foundation for any breast implant revision procedure. The muscle repair offers a number of functional benefits.

Internal bra technique

An "internal bra" is the creation of strong supports for the breast using internal sutures and/or dissolving mesh to reconstruct or reinforce the natural boundaries of the breast.

The original breast reconstruction procedure may have involved deliberate or accidental disruption of the boundaries of the breast. The most common example is the destruction of the natural crease under the breast (the inframammary fold) by dividing the supporting tissues. This may be a consequence of either the mastectomy or the reconstruction. Ideally the reconstructive surgeon would rebuild the inframammary fold at the time of the original reconstruction, but this is often not done.

Depending on the specific problems encountered, the internal bra, in conjunction with precise dissection techniques, allows for repair of the previous damage and strong control of the new implant pocket.

Drainless

Due to the techniques Dr Campbell-Lloyd uses, there is no need to use drains for most breast reconstruction revision procedures. This allows patients to go home on the day of surgery, and is associated with less pain, with no increase in the risk of fluid collections.

Associated procedures:

Fat transfer is almost always performed in conjunction with revising previous breast reconstruction. Fat transfer is the only technique which will allow for correction of contour irregularities, and it can also alleviate the tight, shiny quality of the skin that some women struggle with after implant-based reconstruction. Fat transfer in this context has a slightly different goal when compared to fat grafting for cosmetic purposes, however the basic principles remain the same.

It is important to understand that fat transfer, on its own, is unlikely to be able to offer a patient a total breast reconstruction. Fat transfer is considered an adjunct, rather than a stand-alone technique in most cases. Dr Campbell-Lloyd has written an article discussing the circumstances in which fat transfer may be suitable for total breast reconstruction.

Reasons To Consider This Procedure

Implant revision surgery is far more challenging and extensive than the original breast reconstruction.

There are 5 main reasons that patients ask Dr Campbell-Lloyd to perform revision surgery after implant-based reconstruction:

Shape/contour issues

The typical contour issues we see are irregularities of the breast skin, and lack of definition of the inframammary crease after mastectomy. The lack of crease definition contributes greatly to the poor aesthetics of implant-based reconstruction for some women. By carefully reconstructing the crease, the breast takes on a far more natural appearance.

Capsular contracture

All breast implants are surrounding by a scar tissue capsule. If this scar tightens, it may shrink, gradually squeezing the breast implant. Often the implants become almost spherical under the deforming forces of the contracture.

Capsular contracture may be associated with pain, breast shape changes, and increasing firmness of the breast. Capsular contracture is frequently associated with implant rupture, although the relationship may not be causal.

Implant rupture  

Ruptured breast implants are common, and very frequently an implant rupture is a silent event. Most patients only find out they have a rupture when they seek investigation of some other complaint, like breast pain. The symptoms that lead to investigation are most commonly related to a capsular contracture, but once the rupture has been identified, many patients erroneously believe that it is the rupture that is the cause of their symptoms.

Patients who have had breast MRI or ultrasound scans will sometimes have findings of silicone in lymph glands. This can be seen in patients with, or without implant rupture. This is suggested to occur most commonly due to the accumulation in lymph glands of microscopic silicone fragments which may be shed by textured implants. This finding is typically of little significance and does not require additional management. Dr Campbell-Lloyd does not support the removal of lymph nodes based on these findings.

In general, implant rupture does not represent a health risk. The ruptured implant is contained within the scar capsule, which prevents leakage of the silicone into the breast tissue. It is very likely that a rupture will have been present for a long time prior to being detected. Implant rupture is far more common with older implants.

More importantly, implant rupture does not represent an urgent indication for revision surgery. Feeling rushed into surgery is a likely cause for dissatisfaction with the outcome of revision procedures.

Painful implants

Whilst often associated with capsular contracture, pain can also occur without any evidence of contracture. Pain may relate to pressure effects of breast implants on nerves, and this is nearly always associated with “under the muscle” or dual-plane placement. Ladies who present with implants that have "fallen" out to the side (typically seen when lying down) may be more likely to experience discomfort in the absence of contracture.

Some patients also experience discomfort, which is best described as a sense of tightness, relating to stretching of the Pectoralis major muscle by the breast implants. This can be a significant issue for physically active women who play sports and engage in weight lifting or functional training.

Animation deformity

The movement of the implant (typically upwards, and outwards) due the effect of the Pectoralis major muscle on the implant is referred to as implant animation. Along with movement of the implant, animation can cause distortion of the breast, a widened and flattened cleavage, and pain. After mastectomy, the breast skin tends to adhere to the muscle which will result in unsightly wrinkling of the skin with muscle contraction.

The effect of Pec major muscle contraction after mastectomy with under-the-muscle implants.

Implant animation can feel very uncomfortable, and some patients will actively avoid movements which involve Pectoralis contraction.

What To Expect

In spite of complete correction of capsular contracture or cosmetic distortion of the breast, patients who present with pain associated with implant-based reconstruction may not experience resolution of their discomfort after revision surgery.

All sutures are dissolving sutures, under the skin. A layer of glue is then applied to any incisions. There are no “sticky” dressings applied as this will tend to cause irritation and prevent showering.

After breast implant revision surgery, patients are discharged home with a surgical bra which must be worn at all times for the first 4-6 weeks. In some cases, a "negative pressure" dressing will be applied to the breast for stabilisation and support in the first 2 weeks.

Patients are discharged with antibiotic tablets, and pain-relief medications.

Patients are discharged home with detailed instructions. The instructions include emergency contact details for Campbell-Lloyd.

Routine follow-up appointments are made for:

  • 1-2 days post-op
  • around 1 week post-op
  • subsequently on demand/ as required during the first 6 weeks
  • then at 6 weeks post-op (first post-op photos)
  • and around 4 months post-op (second set of post-op photos, when breast shape has typically resolved, although scars are still settling).

Patients are then seen every 4-6 months as scars fade. Most patients are stable and are discharged at 12-18 months post-op, however we are happy to see any of our patients in an ongoing fashion.

We do not charge for post-op consultations.

There will be some pain. Most patients will experience pain at the incision site in the crease under the breast for the first 7-10 days. Some patients will experience occasional discomforts relating to movement after that time as the healing process continues.

The nature of this surgery is such that patients should expect to require pain relief medication for at least the first 2-3 weeks. Some patients will require simple pain relief (such as Nurofen) for up to 6 weeks as they increase activity.

The internal bra technique may be associated with some additional discomfort. Patients may experience a tight, "band-like" sensation under the breast associated with the muscle repair and internal bra, which can persist for 2-3 months. This is improved with stretching and the resumption of full activity.

It is vital to maintain a decreased level of activity for 6 weeks after surgery to ensure that the muscle repair is not inflamed or aggravated.

It will take at least 3-4 months for full recovery. Final results can only be appreciated after that time, once scars have softened and relaxed. Scars may only fade after 6-12 months on the breast.

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