Breast Reconstruction/Difficult Cases

 Background
 Classfication Of Reonstruction Cases
 Patient Concerns and Planning
 Preparing for Surgery
 The Operation
 Recovery
 At Home
 Office Visits and Follow-up
 Outcome and Complications
 Case Histories (Before and After)

PATIENT CONCERNS AND PLANNING
For patients undergoing secondary surgery to correct asymmetry-associated problems where a previous augmentation was attempted, or if wound healing problems resulted from a prior lift with and without augmentation, it may be necessary to change the present implants if they are older than 4 years, and if they have been manipulated or operated in any way prior to being seen by the current surgeon. Furthermore, if the original implants were large, it may be necessary to reduce the size, when a secondary lift is concurrently planned. Patients must be informed that very large augmentations at the time a revisionary lift is performed can be risky and ill-advised. The expansion of the breast by the implant and the reduction of the skin by the lift can create pressure which can influence properly healing of the surgery. Usually a slightly smaller implant must be used as a replacement when a major lift is planned. If the patient is adamant about seeking a similarly large cup size or an increase in current cup size during the lifting maneuver, the surgeon should recommend the use of postoperatively-adjustable implants of the saline variety. In this way the previous implants can be removed, the scar and pocket issues can be managed, and insertion of new implants can permit adjustments after surgery to prevent this collision of tensions which can cause problems. It is preferred in this Practice to use saline implants at the time of secondary corrective surgery. The rate of implant softness using saline implants appears to be much higher in the series studied since 1992.

The use of silicone gel implants for secondary surgeries of the breast will fall under special FDA and implant manufacturer guidelines. Patients may need to be enrolled in special studies with follow-up requested of the patient for up to 5 years. When a surgeon plans to use silicone gel implants at the time of secondary breast surgery, it may again be necessary to recommend a smaller implant size if a simultaneous breast lift is performed. If no lift is required, then a larger augmentation may be recommended where some internal tailoring or dual plane placement is done to provide a small lift. Other issues critical in the performance of secondary breast augmentation with lift, are related to the use of a pocket behind the muscles, opening that pocket generously at the bottom in a dual plane, use of drains which can remove some fluids that can lead to scarring and capsular firmness, and use of saline implants that avert the possibility of small amounts of silicone gel bleed into the tissues which may have some effect on implant firmness.

Scarring is a major concern for patients undergoing secondary surgery of the breast especially when a breast lift is planned or revised. The use of a periareolar purse string lift leaves a circular scar around the areola. The experience in this Practice has found that a periareolar approach can be applied to practically all cases of prior augmentation where an implant change and new breast lift is planned. For secondary correction of breast lifts originally operated with a vertical or T scar pattern, the periareolar purse string pattern can be designed randomly over the previous pattern so that the skin does not have to been manipulated as much during the corrective surgery.

Antibiotic use should begin prior to the operation, although continuation after the surgery is controversial. When a breast lift and implant change is performed on a difficult secondary case, it may be advisable to use antibiotics for a few days after surgery, up to a week or more. For purse string breast lifts and reductions with and without implants, it may be advisable to use antibiotics for 7 to 10 days following operation to protect the blocking permanent purse string suture in the circular ring around the areola for each breast. Implants should always be handled meticulously avoiding direct contact with the skin prior to insertion.