When Your Breast Reconstruction Result Needs Revision: Fixing common problems

Unhappy with your breast reconstruction outcome? You are not alone, and here is what you can do:

Dr Suzman reviews the best revision breast reconstruction options.

In the 25 years since I first started learning breast reconstruction techniques, there have been incredible advances in breast cancer care.  Breast reconstruction after mastectomy and lumpectomy can be one of the most gratifying, life-enhancing and positive procedures in all of plastic surgery. The results we can now achieve would seem miraculous for a surgeon or patient from when I was growing up in the 1970’s and 80’s  to  my medical school years in the 1990’s. 

However, when things do not turn out well with breast reconstruction, patients can feel anywhere from disappointed to devastated.   Reconstruction plastic surgery is complex, and breast cancer patients can have healing issues, so in some cases poor results do occur despite wonderful efforts from the medical team. 

So if you are disappointed with your breast shape or comfort after breast cancer treatment, you do not always have to settle for poor results-  there are some treatments that can really help for many patients.  Plastic surgery is like sculpture, and operating on the human form is more challenging than working with stone, wood or metal!  But when a talented surgeon has a chance to reflect on how a patient healed, make adjustments once the process is stable, there can be some adjustments that can really help improve shape, comfort and happiness.

I often counsel may patients that breast reconstruction results fall into three categories:

-patients who are thrilled and feel the results are better than their starting breast shape and appearance.  This is often women with very small or very large starting sizes that they were always unhappy with.  The results are often more inline with their ideal size.  Others are thrilled because they expected the worst, are are just happy to be done with surgery and treatment and have a generally positive outlook. 

-those who are satisfied with the outcome, while not perfect, they at least can wear clothes almost normally and not feels deformed or constantly reminded of the breast cancer treatment.  This is the majority of patients. 

-patients who have suffered poor healing, discomfort, multiple surgeries, or are unhappy with the size and shape.  Others have healed well but liked their pre - cancer shape and feel deformed and upset regardless of how they healed. 

How can  we take a person in the third group- unhappy or scared of more treatments-  and treat them in a manner that gets them to one of the first two  “happy” categories?

Here's the good news-- many of the factors that make healing difficult after mastectomy are not present for revision procedures. After breast cancer surgery, the skin of the breast is thin and has had much of the supporting blood vessel supply removed, so the skin has a challenge to heal safely over a reconstruction.  After a number of months or years. The skin is well heled and has a new blood supply of healed arteries and veins and is much better able to heal from surgery.  Also, many breast cancer patients need treatments like chemotherapy and radiation which also keep the body from healing effectively.  So once some one iu s a year or more form these treatments, revising the breast surgery result is much easier and safer.

In one of my original breast revision articles from 2014 I wrote about healing factors that still hold true today:

  “About  6% of patients may have to have their implant removed because of poor healing over the implant.  Sometimes the skin overlying the implant has inadequate blood supply to heal, other times the body generates excessive swelling fluid reaction to the implant (seroma) that impairs healing. Both of these conditions provide “nutrition for bacteria” and can result in  infection and need to remove the implant. Patients with the following risk factors are more likely to have a failed first go at reconstruction: Overweight, multiple medical conditions (high blood pressure, diabetes smoking, known healing or bleeding problems), need for chemotherapy after surgery, previous radiation therapy, thin skin flaps, or skin tension too tight over implant.  If an implant needs to be removed , it usually happens within a couple weeks after the mastectomy surgery.  Patients typically heal well. All hope is not lost! Patients can go on to successful reconstruction. Typically, I advise waiting until after all cancer treatments  are complete. Then, placing  a new tissue expander and resuming reconstruction is possible.  Healing  risk of problems is much lower in this setting, as the skin and tissues over the implant are now stable and healed, not the freshly operated on skin flaps immediately after a mastectomy. If a patient has had previous radiation therapy, then bringing in non-irradiated, healthy skin is essential.  This can include fat grafting from the abdomen or other areas or skin and muscle flaps such as DIEP and TRAM flaps from the tummy. “

Here is a summary of problems that can occur with implant reconstruction and some solutions: 

 

Failed implant reconstruction can occur due to poor healing, seroma, skin loss, or infection. Approximately 7% of patients may need to have their implant removed because of inadequate healing. This can happen if the skin over the implant has insufficient blood supply or if the body produces excessive fluid (seroma) that hinders healing. Both conditions can foster bacterial growth, leading to infection and the need to remove the implant.

Risk factors for failed reconstruction include being overweight, having multiple medical conditions (such as high blood pressure, diabetes, smoking, known healing or bleeding problems), requiring chemotherapy post-surgery, previous radiation therapy, thin skin flaps, or excessive skin tension over the implant. If an implant needs to be removed, it usually occurs within a couple of weeks after the mastectomy surgery. However, patients typically heal well and can pursue successful reconstruction later.

Reconstruction after implant removal is often advised once all cancer treatments are complete. At this stage, placing a new tissue expander and resuming reconstruction is possible, with a lower risk of complications since the skin and tissues are stable and healed. For patients with previous radiation therapy, using non-irradiated, healthy skin is crucial. The latissimus flap from the back is ideal for creating a natural shape over an implant, while abdominal-based flaps can also yield excellent results in suitable patients.

Inadequate Size: Too Little Projection or Too Large and Heavy

Many patients feel their implant reconstruction does not provide the desired size or breast projection. Too little projection is the most common complaint. While there are limits to how large an implant can be or how much tissue expansion is possible post-mastectomy, additional volume can be added after the body has healed (typically over 12 months). This can be achieved with a better-shaped implant or fat grafting.

Patients who started with a single-stage direct-to-implant reconstruction or had limited skin may benefit from switching to a more naturally shaped implant and adding fat grafting. This involves liposuction from the abdomen or thighs, providing gratifying results for both patients and surgeons.

Implants that are too broad, heavy, or large often occur in patients with larger breasts or excess tissue. Downsizing implants and narrowing the skin and soft tissue coverage can significantly improve outcomes in a relatively brief outpatient surgery. Patients often experience less discomfort from downsizing to a lighter implant that stretches the tissues less.

Breast Implant Manufacturers

There are three major breast implant manufacturers in the U.S.: Allergan, Mentor, and Sientra. Each offers a variety of shapes and sizes to achieve the best results, with similar safety profiles. Our practice has found Sientra shaped gels to offer the best results in softness and shape. Mentor provides implants with excellent projection for a fuller look, while Allergan, a long-time leader, offers a wide variety of shapes and sizes.

Rippling or Hollowing of the Upper Chest

In thin-skinned patients, a round implant may not adequately recontour the upper chest. A mastectomy removes breast tissue up to the collarbone, and the abrupt transition from a round implant to the thin chest muscle and ribs can look unnatural, leading to creases and ripples in the skin. Switching to a higher-projected implant can help address this issue.

Congratulations on making it through breast surgery.  We hope this information helps you on your path to years and decades of good health!

Dr. Michael Suzman is certified by the American Board of Plastic Surgeons and has been on faculty at Cornell Medical College, served as Section Chief of Plastic Surgery at White Plains Hospital, served as Board Chair and founded the Renowned Plastic Surgery Department at Summit Medical Group and is on staff at Yale New Haven Health’s Greenwich Hospital.