Revisional surgery following breast reconstruction

After implant

The same complications that were discussed in the section on breast augmentation can also occur in patients undergoing implant or expander based breast reconstruction. The most important complications are capsule formation and capsular contracture.

The main difference between patients undergoing breast augmentation and those undergoing a breast reconstruction following a mastectomy is that the skin envelope is often thin and less well perfused in the latter group. Patients who require radiotherapy following an implant reconstruction, frequently rapidly develop severe capsular contracture.
Although capsular contracture, implant displacement and implant rupture can usually be corrected by replacing the implant or by the use of expanders, it is generally advisable to remove both the implant and scar tissue and perform a reconstruction using the patients’ own tissue.

Complications following implant reconstruction can present in very different ways and it is therefore difficult to describe the best surgical solution for each individual patient. You should contact your plastic surgeon and discuss the possible options. A combination of the techniques described in the chapter on breast reconstruction can be applied to achieve a good aesthetic result. 

Fig. A	Fig. B
Fig. C	Fig. D

Figure 1: (a) result after repeated attempts at breast reconstruction using implants. The patient had radiotherapy on the right side before the implant was removed. On the left side the implant has been distorted by severe capsular contracture. (b,c,d) Result after removal of both the implants and scarred tissue and bilateral free DIEAP flap breast reconstruction, including nipple reconstruction and tattooing of the areolae.

After Autologous

The early and late complications following autologous breast reconstruction were discussed in the chapter on breast reconstruction. It usually takes two to three operations to achieve the final result and therefore most minor problems can be adequately treated during these subsequent procedures. Once the tattooing has been finished, further revisions are rarely necessary.

The main advantage of using one’s own tissue for reconstruction is that it appears natural and lasts a lifetime. However, late complications may arise, although this is unusual. Tattoos do fade though and it may be necessary to re-tattoo the areola at some stage.

Even though abdominal muscle is not removed, or only a small amount is sacrificed, weakening of the abdominal wall muscles where the flap was dissected can occur. However, this is extremely rare. It usually results from stretching of the connective tissue layer of the abdomen or because of suture rupture. If the problem is severe or if it causes functional disturbances, your plastic surgeon must strengthen the connective tissue layer in the abdomen and can gain access through your existing scar.

Breast reconstructions are also subject to ageing, just like any normal breast. Surgical procedures to improve breast shape can also be performed on reconstructed breasts. Additionally, weight fluctuations will cause fluctuations in breast size. In contrast, if an implant reconstruction was selected, the breast volume does not vary. If weight fluctuations do occur, progressive asymmetry between the two breasts may result. The asymmetry is less pronounced in patients who have had reconstructions using their own tissue. One should always remember that the tissue used is usually from the abdomen or the buttock and therefore is more sensitive to hormonal changes than a normal breast. In cases where the asymmetry is very significant, surgery can be performed to either the reconstructed or the normal side.

The small percentage of patients whose previous implant reconstruction or autologous reconstruction failed, can opt to undergo a secondary reconstruction. This can be performed using a new implant, a pedicled flap from the back or a new free flap from the buttocks or the abdomen. However, before embarking on a second procedure it is very important to try and understand why the first procedure failed. Patients who suffer from, for example a coagulation disorder and that led to the flap failure, are excluded from any further microsurgery. However, in most instances a second free tissue transfer can be performed with no greater risk of complications than for the first procedure.

Finally, one should remember that breast cancer can recur and that a new tumor can develop in the reconstructed breast. Although during a mastectomy most of the glandular breast tissue is removed, it is impossible to completely remove all the cells. Any residual cells may produce a further tumour requiring additional surgery. Each patient must therefore be assessed individually to determine how much tissue should be excised and which type of reconstruction should be performed. This should be a combined decision after discussion with your plastic surgeon and the oncologist.

After Breast Conserving Surgery

Patients who undergo conservative surgery and radiotherapy followed by breast reconstruction are at risk of late complications. Most importantly, careful monitoring for recurrence and the development of new tumors in the remaining glandular tissue must be regularly performed. In addition, there is a risk of the potential sequelae of radiotherapy. As is the case following a full mastectomy, a recurrence or new breast tumor may develop after conservative surgery. If it is not possible to perform a local resection, removal of the entire breast, including the partial reconstruction should be performed. In this case one would apply the conventional techniques of breast reconstruction which have already been described.

A specific problem which usually results following conservative surgery and radiotherapy is fibrosis and scarring of the remaining glandular tissue. Radiation injuries can appear 15 to 20 years later. However, most changes occur during the first two years. Deformity of the breast may lead to a significant alteration in the shape and volume of the breast which may necessitate further surgery. A decision must be made regarding which breast to adjust. As before, the techniques used in breast reduction, breast augmentation and breast lift can all be applied. It is important to do as little as possible to the irradiated areas, as wound healing tends to be a problem.

If scarring and fibrosis is severe it may be necessary to remove the entire breast and reconstruct it using one of the previously described techniques.

After nipple reconstruction

A nipple reconstruction may flatten due to changes in volume or secondary to the ageing process. Typically, the nipple loses projection after a few years. A short and simple operation can enlarge the reconstructed nipple. Additional tattooing of both the nipple and areola is then also required. Tattoos tend to fade anyway and often have to be repeated several years later.

Poor positioning of the nipple and areola is usually a result of bad pre-operative planning. Sometimes, the position of the nipple may be altered by scarring or the side effects of radiotherapy. If the areola is displaced too far from its natural position and cannot be simply repositioned, the nipple reconstruction may have to be abandoned and started over again in the correct location.