What Can Breast Reconstruction Revision Correct?

Breast Asymmetry

Patients with unilateral mastectomy may find that the newly constructed breast sits higher on the chest wall and looks less natural than the natural breast. I can make the reconstructed breast look more natural, while making the natural breast look more symmetric by creating lift and adding fullness to the upper portion of the breast. I like to refer to this as naturalizing the fake breast, and “fakifying” the natural breast. Typically, naturalization of the mastectomy side means that we make sure the implant position is correct, and add a thick layer of fat to increase softness and hide implant edges. On the natural side, we move more toward a high, lifted breast. I created my pocket lift to permanently hold up the natural breast to match mastectomy reconstruction, which gives the breast upper pole fullness, even without an implant.

Capsular Contracture

Capsular contracture occurs when a hard capsule of scar tissue forms around a breast implant and constricts the implant to the extent that it causes the breast to feel like it’s encased in a hard shell. Severe cases of capsular contracture can cause the breast to look misshapen and be painful.

To cure capsular contracture, a combination of capsulectomy and dermal matrix is used. The breast implant is first removed from the breast pocket and then the capsule is completely excised. The area is treated to eradicate any biofilms or silicone. Once the capsule has been removed, I place an acellular dermal matrix in the excised breast pocket to create a structure that is more natural-looking—and functions much like an internal bra. This additional support allows the breast implant to sit in the correct position and minimizes the chances of forming new scar tissue following breast reconstruction revision surgery.

This is a highly successful surgery which can be performed on radiated breasts. Capsular contracture patients must also be tested for biofilms, which are low grade bacterial contaminations of the implants that must be eradicated for cure.

Unsupported, Low, Or Armpit (Lateral) Implants

A common mastectomy outcome following breast reconstruction is a breast with a visible and unsupported implant, which can move out of position and feel heavy. Patients may find that implants have a noticeably wide distance between them, creating an upper chest that is hollow-looking with visible rippling of the implants. The implants may fall to the sides when you lie on your back, and you may need to wear a bra all the time.

This is primarily an implant support problem. Most of these patients need a strong internal bra-like support structure to the capsule to keep the implant in position. For most patients, I use absorbable mesh to build this internal support, which does not stretch over time as much as acellular dermal matrix. This will not only hold the implant where we want it, but allow you to go bra-free. I may switch you to a cohesive gel implant as they are least likely to ripple. We also discuss if it would be beneficial to perform fat grafting above and between the breasts. This provides a full and natural appearance while avoiding a visible implant step-off and cleavage gap issues.

Reverse Tissue Expansion And Fat Graft Replacement Of Implants

Many mastectomy patients are sick of their implants, which may be painful, feel foreign, need to be replaced over time, or are concerned for health issues. Implants can be replaced by fat over time using serial fat grafting, and reducing the size of the implant and ultimately removing any silicone device. The surgery can take place in different ways, and it depends on the patient. For patients with very large implants, the implant is downsized, and fat graft is added to the mastectomy flap. Multiple surgeries may be necessary where fat is added, until the implant is removed.

For patients with smaller implants, the total volume is lower, which makes the replacement with fat easier. In this case, the implant size is usually diminished once with a fat grafting surgery, and then the implant is removed in the subsequent surgery.

For all patients hoping to remove their implant and replace them with fat, there does need to be adequate fat on the body to harvest and place in the mastectomy flap. A good rule of thumb is that the fat in the breast area can be doubled with each surgery. Therefore, the first fat graft is the smallest amount that is placed, followed by larger and more significant amounts with each surgery and more impressive results. The surgeries are usually done 6 months apart, which allows adequate time for the fat to permanently live in the new location. Most patients require between two and four surgeries, with recovery similar to liposuction. Patients with submuscular implants will also require repair of their pectoral muscles for complete reconstruction, which is typically done on implant removal. Patients with a history of radiation are excellent candidates for replacement, as the fat graft has not been radiated and will typically restore a more normal appearance and feeling to the radiated breast.