Why Do Patients Seek Revisionary Breast Surgery?

Breast Surgery Why Do Patients Seek Revisionary Breast Surgery? Navanjun S. Grewal, MD; and Jack Fisher, MD In 2011, according to the American Society for Aesthetic Plastic Surgery (ASAPS), 316 848 American women underwent breast augmentation and 112 964 underwent breast reduction surgery. 1 These 2 procedures rank in the top 10 among all procedures (surgical and nonsurgical) performed annually. Breast surgery patients desire symmetry, softness, and longevity of results. Over a lifetime, the majority of those breast surgery patients who do seek secondary revisions are attempting to correct ptosis, capsular contracture (CC), malposition, or simply to make a change in size and shape. With reoperation, there is an increased risk of complication, and good cosmetic outcomes may be difficult to Aesthetic Surgery Journal 33(2) 237 244 2013 The American Society for Aesthetic Plastic Surgery, Inc. Reprints and permission: http://www.sagepub.com/ journalspermissions.nav DOI: 10.1177/1090820X12472693 www.aestheticsurgeryjournal.com Abstract Background: Patient motivations for revisionary breast surgery following breast augmentation, mastopexy-augmentation, and breast reduction are often overlooked. Most patients presenting for a revision do so because they desire a subsequent improvement in their appearance or wish to correct a problem resulting from the primary operation. Objective: We present and analyze the clinical indications for revisionary breast surgery in a series of 134 consecutive cases. Methods: We retrospectively reviewed the charts of 134 patients who underwent revisionary breast surgery in a single clinic from 1994 to 2009. Patients were grouped based on operative procedure: augmentation (n = 110), mastopexy-augmentation (n = 10), bilateral breast reduction (n = 15), breast malformation correction (n = 1). Three categories were also specified according to the cause for secondary surgery: (1) the surgeon s operative plan was flawed and/or involved a technical error, (2) an independent factor occurred such as ptosis or capsular contracture, or (3) there was a combination of both factors. Results: The most frequent reasons for revisionary surgery among aesthetic implant patients were the development of ptosis (42%), capsular contracture (29%), and lower-pole deformities (19%). Twenty-six percent of patients had a combination of problems. Revision among breast reduction patients was due to volume loss from overresection (40%), nipple-areola loss (27%), and breast asymmetry (27%). The average time between the first surgery and reoperation was 8.9 years for augmentation, 4.3 years for mastopexy-augmentation, and 2.9 years for reduction. In implant patients, the biggest problem leading to revisionary surgery was natural progression (66% augmentation, 90% mastopexy-augmentation). However, among breast reduction patients, 73% of revision requests were a result of problems with surgeon judgment or technique. Conclusions: Our study demonstrates that although the rate of surgeon-specific problems was high in reduction patients, overall, independent factors were the primary reason patients sought revisionary breast surgery. This may be contrary to commonly held beliefs that attribute poor results and revision requests to incorrect surgical technique and erroneous surgical decision making. Level of Evidence: 4 Keywords revisionary surgery, breast surgery, breast augmentation, mastopexy, breast reduction Accepted for publication July 11, 2012. achieve. 2,3 Correcting the problem requires an understanding of the primary operation and the endurance of the From the Department of Plastic Surgery, Vanderbilt University, Nashville, Tennessee. This article was previously presented at The Aesthetic Meeting 2012, the annual meeting of the American Society for Aesthetic Plastic Surgery, May 3-8, 2012, in Vancouver, BC, Canada. Corresponding Author: Dr Jack Fisher, 310 23rd Avenue North, Suite 101, Nashville, TN 37203 USA. Email: jfisher@drjackfisher.com

238 Aesthetic Surgery Journal 33(2) surgically altered breast. No peer-reviewed studies have been published that analyze the circumstances leading to a patient s presenting problem. Many patients and surgeons consider secondary breast surgery a consequence of the initial surgical technique and a failure to choose the correct operation for the patient. This article is aimed at improving our understanding of this complex association. Methods A retrospective review of 1000 charts was conducted on all consecutive patients who underwent breast surgery in a 15-year period from 1994 to 2009 in a single clinic. Patients were excluded if they had undergone breast reconstruction, minor scar revisions, early reoperation for hematoma/seroma/wound dehiscence, or if their charts had incomplete data. In addition, patients who only had one primary breast operation (ie, they never presented for a revisionary surgery) were excluded. Data were collected on revisionary breast surgery for the following groups: (1) augmentation, (2) mastopexy-augmentation, and (3) bilateral breast reduction. The senior surgeon performed all of the revisionary cases (J.F.). Information recorded included patient s age, prior breast surgery, clinical indication for revision, interval to revisionary surgery, corrective surgical procedure, success of the revision, and complications. Corrective procedures performed included secondary mastopexy, capsule surgery, implant exchange or explant, and change of implant location, type, or size. Three categories were used to isolate the original mechanism of failure that resulted in an unsatisfactory result requiring a secondary surgery. In category 1, the surgeon s operative decision was flawed or involved technical error such as placement of oversized implants, inadequate or overdissection of the pocket, inaccurate implant positioning, and failure to address the skin envelope. In category 2, 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 of conditions in this category included CC, breast asymmetry, breast cancer, and infection. In category 3, a combination of both factors for instance, ptosis and asymmetry took place. During the review of revisionary breast surgery patient charts, methods used to categorize the mechanism of failure included a review of pertinent clinical notes (eg, physical exam) and original operative notes (when available). The authors were the only individuals involved in chart collection and photograph review. An independent biostatistician analyzed any relevant data regarding outcomes, complications, and revision rates. Statistical analysis with a t test was used to compare the groups. Results A total of 134 patients (operative procedure: augmentation, n = 110; mastopexy-augmentation, n = 10; bilateral breast reduction, n = 15; breast malformation correction, Figure 1. Indications for revision in breast augmentation and mastopexy-augmentation patients. n = 1) required revisionary breast surgery. Of the patients with prior implants, 68 patients (51%) had subglandular implant position, whereas the implant position in 66 patients (49%) was either partially or totally submuscular. Silicone gel devices had been placed in 102 patients (76%) with prior implants, whereas 32 patients (24%) received saline implants at the initial operation. Among the breast reduction patients, 13 (87%) had inverted T-scar skin approaches, whereas 2 (13%) had undergone vertical-scar reduction mammaplasty. The average age at revisionary surgery was 38.2 years (range, 18-73 years). The average time between the first surgery and reoperation was 8.9 years for augmentation, 4.3 years for mastopexy-augmentation, and 2.9 years for reduction. The average follow-up period was 5.4 years (range, 1-23 years) after revisionary breast surgery. To date, all revision patients are satisfied with their appearance. Ninety-three patients (69%) had their original surgery performed by outside surgeons. The additional 42 patients (31%) were previously operated on by the senior author (J.F.). Of the author s own secondary patients, the average time to revision was 6.1 years for augmentation (n = 35/42 patients), 2.1 years for mastopexy-augmentation (n = 4/42 patients), and 2.0 years for breast reduction (n = 3/42 patients). The most frequent reason for revisionary surgery among augmentation and mastopexy-augmentation patients was the development of ptosis (42%), followed by CC (29%), lower-pole deformity/high-riding implant (19%), implant malposition (14%), exposed implant due to infection/ extrusion/excessive augmentation (7%), breast cancer (5%), rippling/implant visibility (4%), synmastia (4%), double breast contour or double-bubble deformity (3%), and deflation (2%) (Figure 1). Among breast reduction patients, revision was primarily necessary because of volume loss due to overresection (40%), followed by nippleareola loss (27%), breast asymmetry (27%), and recurrent ptosis (13%) (Figure 2). Corrective secondary procedures varied among the different groups of patients (Table 1). For implant patients, major corrective procedures included a combination of

Grewal and Fisher 239 Figure 2. Indications for revision in breast reduction patients. Table 1. Corrective Procedures for Revision Primary Operation Surgical Procedure(s) No. (%) of Patients Augmentation and mastopexy-augmentation (n = 120) Mastopexy 43 (36) Capsule surgery 56 (47) Change of implant type, location, and/or size 67 (56) Breast reduction (n = 15) Insertion breast prosthesis 6 (40) Flap reconstruction 2 (13) Nipple-areola reconstruction 4 (27) Secondary mastopexy 3 (20) mastopexy for preexisting and secondary ptosis (n = 43/120), capsule surgery for shape problems (n = 56/120), and change of implant location/type/size (n = 67/120) (Figure 3). Meanwhile, for breast reduction patients, surgical correction involved insertion of a breast prosthesis (n = 6/15) and/or flap reconstruction (n = 2/15) to restore lost breast volume, nipple-areola reconstruction (n = 4/15) with local flaps, and secondary mastopexy (n = 3/15) (Figure 4). In our patient series, the primary cause of implant patients seeking revision was a factor independent of surgical technique (augmentation, n = 73/110; mastopexy-augmentation, n = 9/10). However, breast reduction patients primarily sought revisionary surgery because of surgeon error (n = 12/15; Figure 5). Two implant patients (2%) and 1 breast reduction patient (6%) had a combination of surgeon error and independent factors. Two patients in our series (1%) required a revision of a prior revision. The first patient was a 44-year-old woman who had undergone mastopexy-augmentation to correct overresection deformity after an inferior pedicle, Wisepattern breast reduction 3 years earlier. After 6 years, she re-presented with recurrent ptosis, and her revisionary procedure involved an inverted-t mastopexy with placement of acellular dermal matrix (ADM) and implant exchange (Figure 6). The second patient was a 30-year-old woman who had undergone subglandular augmentation in which the implants were filled with intraluminal steroid solution 4 years earlier. The consequences included significant tissue distortion and bottoming out. She underwent removal of her implants and, after 6 months, underwent capsule surgery, repair of synmastia, and a mastopexy-augmentation. After 3 months, she represented with recurrent synmastia and malposition. The second revisionary procedure involved capsule surgery. One patient required correction of breast malformation. She was a 49-year-old woman who, 25 years earlier, had undergone direct silicone injections for breast augmentation. She presented with multiple bilateral recurrent abscesses, mastitis, and granulomas. She underwent bilateral subcutaneous mastectomies following by immediate breast reconstruction with bilateral pedicled (transverse rectus abdominis myocutaneous [TRAM]) flaps. Discussion Breast surgery remains a common aesthetic procedure. Few women contemplate the possibility of unfavorable results. Breast augmentation can lead to unsatisfactory results if surgical technique is careless and inappropriate implants are selected. Mastopexy procedures designed to reshape the breast by tightening the skin envelope have limitations when simultaneous augmentation is performed. Furthermore, breast reduction presents a challenge, requiring the surgeon to resect adequate parenchyma while maintaining the blood supply to the nipple-areola complex (NAC) and skin flaps. Patients seek secondary breast surgery due to consequences from these primary breast operations, and these revisionary surgeries are complex. Over 30 years ago, Baker and Schultz 4 developed a classification scale to measure the level or degree of hardness in an augmented breast. The incidence of CC has decreased over time with implant handling considerations, 5 submuscular position, 6 better technique to minimize seroma/ hematoma, 2,7 irrigation with antibacterial solutions, 8,9 and newer types of implants. 10 These considerations are important in designing a soft, natural-looking breast. In this study, we classified CC as a factor independent of the surgeon s technique. Reoperation rates in the breast surgery literature have run as high 19.4% for primary augmentation with silicone gel implants and 23.1% for saline implants. 11,12 Codner et al 13 performed 634 primary breast augmentations and 178 mastopexy-augmentations over a 15-year period. The most common complication was CC at 8.2%, followed by

240 Aesthetic Surgery Journal 33(2) Figure 3. (A, C) This 38-year-old woman had undergone breast augmentation with subglandular saline implants (425 cc) 13 years prior to presentation. She presented with ptosis and Baker grade 3 capsular contracture. This patient s presentation was considered a result of natural, independent physical factors (category 2). (B, D) Five months after bilateral capsulectomy, implant exchange to submuscular silicone gel implants (400 cc), and periareolar mastopexy. rippling in 7.1% of patients. The reoperation rate in this study was 16.3% in the mastopexy-augmentation group for secondary ptosis and 9.6% in the augmentation group for implant-specific reasons. The most common reoperative procedure in the Codner study involved treatment for CC, which parallels our study. Our study indicated that the majority of implant patients presented due to surgeon-independent factors. As humans age, skin becomes thinner, losing elasticity and collagen, so breast volume and shape change. These breast effects are amplified with fluctuations in weight, pregnancy, and some hereditary factors. This leads to natural sagging of the breasts, or ptosis. These processes are accelerated with the sharp increase in breast volume after implant placements, which place significant tension on the skin envelope. In addition, although the risk of developing CC is highest during the first year, the occurrence increases over time, 14 making it a common indication for revisionary surgery. Handel 15 analyzed factors that increase morbidity of secondary mastopexy in the augmented breast. He stressed importance of proper planning, attention to detail, and a combination of breast lift, capsule surgery, and implant exchange. Spear et al 16 provided primary augmentationmastopexy outcomes data involving 34 patients over a 6-year period. Of the 34 patients, 54% desired revision surgery with an expressed desire for a greater lift of the breasts. Secondary mastopexy-augmentation after previous mastopexy-augmentation is rarely discussed in the literature. Dickinson et al 17 created an algorithmic approach to address factors such as blood supply to the NAC, incision approaches, and desire to reduce or increase breast volume.

Grewal and Fisher 241 Figure 4. (A, C) This 46-year-old woman had undergone inverted-t pattern breast reduction 6 years prior to presentation. She presented with markedly small breasts and lateral malposition of the nipples. Her presentation for reoperation was considered a result of surgeon error (category 1). (B, D) Nine months after placement of adjustable saline implants and Wise-pattern revision mastopexy. Figure 5. Mechanism of failure that leads to revisionary surgery. Surgeon errors, such as placement of oversized implants, create distorted or asymmetric breasts. Technique error during pocket dissection creates lower-pole deformities, synmastia, and double-bubbles. However, according to our results, these technical complications are not the primary reason patients seek revisionary surgery in previously augmented breasts. However, we found that revisionary breast reduction patients primarily present with problems as a direct consequence of the original operation and surgeon error. Hammond and Loffredo 18 nicely described the complications unique to breast reduction as NAC necrosis and shape change (eg, bottomingout). Reoperation/revision rates for breast reduction are as high as 9% 19 but depend on the experience of the surgeon with a particular technique. In our series, another reason breast reduction patients sought secondary surgery was overresection. In the vast majority of instances, some type of insurance is used to pay for the cost of breast reduction. For patients to qualify, a minimum amount of breast tissue must be removed. In some patients, this will create very small breasts, and these patients may seek revisionary surgery to increase volume (eg, secondary implant placement). Unfortunately, our small patient sample size in the breast reduction category (n = 15) did not allow for other conclusions beyond these to be drawn. A possible solution would be to collect revisionary breast reduction data using a standardized collection

242 Aesthetic Surgery Journal 33(2) Figure 6. (A, C) This 44 year-old woman had undergone an inferior pedicle Wise-pattern breast reduction 3 years prior to presentation. She presented with an overresection deformity. (B, D) Five months after mastopexy-augmentation with submuscular silicone gel implants (325 cc). (E, G) Six years after her first revisionary surgery, the patient demonstrated recurrent ptosis and bottoming out. (F, H) Two months after inverted-t mastopexy with creation of a neopectoral pocket, placement of acellular dermal matrix, and implant exchange (silicone gel implants, 300 cc). methodology from multiple practices to better understand why this subset of patients seeks secondary surgery. Another limitation of this study is our inability to measure the revisionary rate of all primary breast cases performed by the senior author over the time period. Unfortunately, patients sometimes seek out new surgeons due to changes in location or dissatisfaction with their immediate or long-term results. A follow-up study could attempt to contact every primary breast surgery patient and determine if and why they underwent revisionary surgery. Pooled data from different plastic surgery practices could add increased value to this study to avoid bias from a single surgeon s experience. Despite the limitations in our study, we believe that our data reflect a typical general practice and avoid the bias that a practice devoted to revisionary breast surgery would likely see, which would lean toward correction of only technical problems and poor operative planning. Conclusions Corrective breast surgery is significantly more complicated than primary augmentation, mastopexy-augmentation, and primary breast reduction. In the majority of cases, the long-term presence of implants changes breast anatomy and contributes to accelerated ptosis and possible capsule formation, which were the 2 most common indications for revisionary surgery in our patient series. Understanding the original operation and natural progression after breast surgery can help achieve successful outcomes in the majority of revisionary cases.

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