Why Do Patients Seek Revisionary Breast Surgery?

Goals/Purpose: Patient motivations for revisionary breast surgery following aesthetic breast augmentation, mastopexy-augmentation, and breast reduction are infrequently discussed in the literature. The majority of patients desire a subsequent procedure to restore symmetry, improve appearance, shape, softness, and sometimes to correct a problem resulting from the primary operation. No published peer-reviewed studies have been identified which analyze the explanatory circumstances that lead to a patient's presenting problem.

 

Methods/Technique: A retrospective review of over 1000 charts was conducted on all patients who underwent revisionary breast surgery by a single plastic surgeon in a 15-year period from 1994 to 2009. This study excluded minor scar revision and patients with incomplete data. Patients were grouped based on the original operative breast procedure – augmentation, mastopexy-augmentation, or reduction. Patient charts were reviewed for a number of parameters including clinical indication for revision, interval to revisionary surgery, corrective surgical procedure, and success of the revision. Corrective procedures performed included mastopexy, capsule surgery, implant exchange or explantation, and change of implant location, type, or size. Three categories were created to isolate the original mechanism of failure that resulted in the need for secondary surgery. In category I the surgeon's operative decision was flawed or involved a technical error. In category II a factor independent of the surgeon's choice occurred such as ptosis due to involution of breast tissue with aging, pregnancy, or weight loss. Other examples include capsular contracture, breast asymmetry, breast cancer, and infection. Category III is a combination of both factors.

Results/Complications: A total of 134 patients (augmentation n=110, mastopexy-augmentation n=10, bilateral breast reduction n=15, breast malformation correction n=1) needed reoperation. Forty-one patients (31%) were previously operated on by the senior author. The additional 93 patients (69%) had original surgery performed by outside surgeons. Among the revisions 61 patients (51%)  had originally subglandular implants, while 59 patients (49%) were either partly or totally submuscular.

The most frequent reason for revisionary surgery among augmentation and mastopexy-augmentation patients was the development of ptosis (40%), followed by capsular contracture (29%), lower-pole deformity / high-riding implant (19%), implant malposition / asymmetry (14%), rippling / waviness (4%), double-bubble deformity (3%), exposed implant due infection /  extrusion / excessive augmentation (7%), synmastia (4%), breast cancer (5%), and deflation (2%). Twenty-six percent of patients had a combination of problems. While among breast reduction patients' revision was necessary because of volume loss due to overresection (40%), nipple-areola loss (27%), breast asymmetry (27%), and recurrent ptosis (13%). One patient (6%) had a combination of technical error and natural history. The average time between the first surgery and reoperation was 8.9 years (augmentation), 4.3 years (mastopexy-augmentation), and 2.9 years (reduction). In our series the average age at revisionary surgery was 38.2 years (range, 18 – 73). The most significant problem that leads to need for revisionary surgery was natural progression (66% augmentation, 90% mastopexy-augmentation). However among breast reductions poor surgeons judgment or technique lead to a 73% revisionary rate.

Two patients (1%) in our series required a revision of a prior revision. The first patient was a 44 year-old woman who had mastopexy-augmentation to correct deformity after an inferior pedicle Wise pattern technique breast reduction 3 years earlier. After 6 years, she represented with recurrent ptosis and revisionary procedure involved inverted T mastopexy and implant exchange. The second patient was a 30 year-old woman who had a mastopexy-augmentation after subglandular augmentation in which the implants were filled with intraluminal steroid solution 4 years earlier. After 3 months, she represented with synmastia and the revisionary procedure involved capsule surgery.

Conclusion: Corrective breast surgery is significantly more complicated than primary augmentation, mastopexy-augmentation, and breast reduction. In the majority of cases, our study demonstrates that factors independent of the surgeon's decision-making or techniques are the primary reason patients seek revisionary breast surgery. The long-term presence of implants changes breast anatomy and contributes to accelerated ptosis and possible capsule formation, which were our two most common indications for revisionary surgery. This is contrary to commonly held beliefs that blame surgical technique and bad decision-making on undesirable long-term results. Understanding the original operation and natural progression after breast surgery can help achieve successful outcomes in the majority of revisionary cases.

Figure 1. Natural History. Breast Augmentation.

38-year-old woman had subglandular augmentation with saline implants (425cc) 13 years earlier. She presents with ptosis and capsular contracture. Revisionary surgery included bilateral capsulectomy, implant exchange to 400-cc silicone subpectoral implants, and periareolar mastopexy.  Preoperative (top row) and postoperative views (bottom row) at 5 months.

Figure 2. Surgical Error. Breast Reduction

46-year-old woman who had inverted T pattern breast reduction 6 years earlier.  Patient presents with markedly small breasts and lateral malposition of the nipples. This patient was successfully treated with placement of adjustable saline implants and revision mastopexy. Preoperative (top row) and postoperative views (bottom row) at 9 months.