Reoperative plastic surgery in every area of the body is fraught with more challenges and greater potential for difficulties and disappointments than is primary surgery. This is definitely true for reoperative surgery of the breast. Nevertheless, as surgeons, we are all aware that a great deal of satisfaction can be achieved by an appropriately timed, well-planned, and accurately performed revisional surgery procedure.

For the best possible outcome to occur in the setting of reoperative surgery, it is paramount that both the surgeon and the patient be prepared and ready for surgery. For the surgeon, this means that he or she has made a diagnosis, understands the important anatomic details, has formulated a sound surgical plan, and has explained that plan to the patient. The surgeon must be sure that the patient is physically
and emotionally prepared to undergo another surgical procedure.

It is important for the surgeon to connect with the patient. Toward this end, it is essential for the surgeon to demonstrate a true sense of caring and concern for every patient. In practical terms, the surgeon must convey a sense that he or she is genuinely interested in helping the patient with her problem. First and foremost, this entails having an understanding of the patient’s concerns, disappointment(s) with previous surgery, motivations, and goals. It is critical that the surgeon spend the time necessary to communicate with the patient in an honest and sensitive way about her problem so as to establish a positive doctor-patient relationship. This relationship will provide the background for the best possible patient outcome and be the primary means of supporting the patient if the revisional surgical procedure results in less of an improvement than expected, or in additional problems or complications.

When seeing a patient with a difficult problem, the surgeon should be upbeat, understanding, and supportive. I have found that greeting the patient with sincerity and meaningful eye contact is always helpful. The surgeon must be sensitive to the patient’s needs, and most of all he or she must be honest with the patient.

Honest communication between the patient and the surgeon is the key. It is important for the surgeon to explain to the patient his or her assessment of the patient’s current condition and what the reasonable expectations from additional surgery are. The surgeon must spend a significant amount of time educating the patient and building her confidence. Investment of time in and honest communication with the patient are always important, and they can pay huge dividends throughout the healing process and over the long term.

It is important for the surgeon to gather as much information as possible about the previous procedure(s). This starts with gathering information from the patient herself, but in many cases more specific and detailed information should be garnered from a review of operative records and previous offices notes, or from direct communication with the previous surgeon(s). Such information is usually extremely helpful in formulating an operative plan. In this regard, it may be important for the surgeon to obtain permission from the patient to contact the previous surgeon. For example, in the setting of a previous mastopexy or breast reduction, it is critically important to understand the orientation of the blood supply to the pedicle that was used. Or, in the case of reoperation in the setting of a previous breast augmentation, the size, position, and type of implant are very important to know in all cases.

I find it helpful to have the patient request her previous medical records so that I can review these in detail. This is done in writing, and we have the forms in our office to facilitate the process. If there are issues in the patient’s previous care that I do not understand, I will ask the patient’s permission to directly contact her previous surgeon.

Along these lines, it is important for the surgeon to gain insight into a patient’s feelings about her previous surgeon. Many times it is apparent that the previous procedure was well planned and executed and that only a minimal revision may be necessary. In this setting, I will often encourage the patient to pursue further contact with the original surgeon, especially if I personally know him or her to have a high level of competence and concern. Obviously the decision to return to the original surgeon must be left up to the patient.

If the patient appears especially critical of her previous surgeon(s), this may represent a red flag, and extreme caution must be exercised when deciding whether to accept her as a new patient. This is particularly true if the result obtained from the previous surgery was relatively good but the patient expresses multiple criticisms about her result. Such patients are typically difficult to satisfy, and if you decide to reoperate, you may be the next surgeon she is critical of.

The breast is a very important organ in every woman’s life, and it contributes greatly to the patient’s body image and sense of femininity. Different patients have different levels of psychologic investment in their breasts. As part of the initial evaluation, it is critical for the surgeon to understand how many surgical procedures a patient has had and which ones were elective. Multiple previous aesthetic procedures can often indicate a patient whose own body image is poor and may identify a patient who has unobtainable expectations from surgery.

A decision to proceed with revisional surgery can be made following the initial visit, but it is more often established following a second consultation. In complicated cases, however, it is often helpful to see a patient several times before deciding to proceed with surgery. This allows the surgeon to clarify the details of the operative plan (e.g., outline for the patient the proposed incisions and position of implants) and permits a careful review of operative goals, anticipated recovery time, and potential risks and complications. Most important, it allows the surgeon to make sure that the patient and surgeon are on the same wavelength with regard to the goals, anticipated results, and limitations of additional
surgery. There is no charge for additional surgical consultations in this setting.

As previously alluded to, consistent success in every area of plastic surgery requires an understanding of the patient’s chief complaint and goals, a careful analysis of the problem and pertinent anatomy, a highly individualized operative plan, and consistent surgical technique.

In complicated cases, or those in which multiple procedures have already been performed, a thorough understanding of the surgical problem and a well-thought-out approach for its improvement is critical on the part of the surgeon. This is only possible after a careful and compulsive history and systematic physical examination are completed. The formulated plan is discussed in detail with the patient and at least one support person (spouse, relative, or close friend), and during this discussion the potential risks of additional surgery must be spelled out as completely and clearly as possible. I find that having a support person there is important for the patient. That person helps to clarify details for the patient and is there in the event that additional complications arise. Only when I am satisfied that the patient understands the risks and is psychologically and physiologically prepared for surgery do we proceed.

The patient herself is the best person to define her expectations from a surgical procedure and to demonstrate the aspect(s) of her breast appearance that she wants to change. I place the onus on her in this regard and ask her to precisely describe her goals in terms that both she and I understand. I will often have her stand in front of a full-length mirror and point out on her breast(s) precisely her areas of concern.

It is important for the surgeon to have a good idea of what the patient thinks about her breast size, shape, and previous scars. The surgeon must also understand any concerns she has about placing additional scars on her breast(s) from the standpoint of length and position because often additional scars will be required to achieve the changes that are requested. The surgeon must carefully explore and understand the patient’s feeling about her breast symmetry because asymmetry is a very common reason for requesting additional surgery. Is she willing to accept the placement of an implant or have additional scars placed outside the breast if it is determined that the addition of a flap may be necessary to optimize her breast appearance and symmetry?

The patient must have realistic expectations about what is possible with additional surgery and what is not possible. For example, many patients request that I eliminate scars from a previous procedure or eradicate the possibility of developing another capsular contracture following a complicated implant operation. Another example is that of a patient who has an unsatisfactory breast shape produced by an implant that is inappropriately large for her physique and who wants to have still bigger breasts following an additional breast procedure. Often patients do not understand the limitations of an operation imposed by suboptimal or compromised tissue elasticity and the presence of scar tissue, or they do not comprehend the undeniable reoccurrence of breast ptosis following every mastopexy procedure. Many times their ideas result from having an inadequate understanding of the likely outcome and limitations of surgery. A true awareness of realistic expectations results from having an increased understanding of the surgical procedure(s), and in my experience this must be derived from patient education on the part of the plastic surgeon and his or her trained staff.

Patient education is in a real sense one of the most important aspects of a physician’s job. Other than the precise performance of a well-planned procedure, it may be the most important part of the plastic surgeon’s practice.

We live in an age of information availability, as evidenced by the plethora of information present in many lay publications and on many Internet websites. In general this is a good thing, but it has its negative points as well. Material contained on various websites about cosmetic and reconstructive breast surgery can provide the patient with much useful background information for understanding some of the issues relating to breast surgery, but it is often incomplete and nonspecific. Although today’s patients in many ways are more sophisticated than patients in the past in their knowledge about some aspects of breast surgery, there is very little material they can review about reoperative surgery and the details related to it.

In this regard the surgeon must be both a good communicator and an educator. It is essential for the surgeon to review with the patient and make sure she understands the operative plan, why it was chosen, the necessary placement of incisions, the likely duration of the recovery, and the potential risks and complications. I find it helpful to point out the placement of incisions on the patient’s breasts or on a diagram of the breasts, or to show the patient photographs of different patients who have had similar procedures. When using photographs as a means of patient
education, it is important for the surgeon to show a range of outcomes and illustrate average surgical results. It is essential for the surgeon to be honest and not paint an overly rosy picture of potential outcomes. In addition, it may be helpful for prospective patients to speak with patients who have had one or more reoperative surgical procedures in a similar setting. Not uncommonly the optimal correction of a problem may require two operations (e.g., the placement of a tissue expander before an implant for reconstruction of a severely constricted breast deformity with a “double bubble” that is present after the initial treatment). The patient must be aware of the need for this type of plan and accept the physical and financial consequences of possibly having two procedures.

Having an accurate sense of the patient’s understanding of the proposed procedure and insight into her situation is an absolutely critical component of patient selection and is the most important reality test for the surgeon.

Following a consultation and thorough evaluation of the patient’s problems, often the best course of action is not to reoperate. In these situations the patient must be told no, but I will do everything I can to explain my decision by presenting it to her in a way that reflects sensitivity about her problem. As a doctor your duty is always to advise the patient on what you believe to be the best course of action. Therefore, do not be afraid to sensitively and diplomatically convey to the patient that you believe that it would be best not to perform additional surgery if this is your conclusion.

Alternatively, if I believe that an operation might be possible but that I am not the surgeon with the experience or surgical skill to perform the surgery successfully, I will refer her to a colleague who might better meet her needs.

If it is determined that a patient has realistic expectations and presents with a problem that I can address with a good chance of improvement, she is most often a good candidate for surgery and the process of preparing her for a revisional operation then proceeds. The options for treatment of her particular problem are reviewed, and the procedure I believe will work best is explained. Included in the explanation of the surgical procedure is my choice for anesthesia. Many operations on surface tissues (the skin and breast parenchyma alone) can be performed under local anesthesia with intravenous sedation. This includes most scar revisions, minor modifications of a previous mastopexy or breast reduction, and revision of many types of breast reconstructions. For more involved deep layer procedures with significant tissue shifts, implant changes with extensive work on the periprosthetic capsular tissue, or surgery on the muscle layer, I prefer general anesthesia and will suggest this to the patient. The intraoperative management of the patient’s anesthetic needs by trained and experienced anesthesia personnel allows me to focus all of my attention, concentration, and creative energy on the patient’s surgical problem without concern about the patient’s overall state of comfort, level of sedation, and safety. In either case I will often have the patient consult with the anesthesia service before the planned procedure.

Timing is a very critical element in reoperative surgery and is integral to its success. As previously stated, both the patient and the surgeon must be optimally prepared. For the patient, this relates to psychologic, physiologic, and anatomic factors.

The patient must be emotionally ready for another surgical procedure. This is especially important in the setting of elective surgery. This means that sufficient time has elapsed to permit the patient to clearly focus on recuperating from additional surgery. From a physiologic and anatomic perspective, this usually means that the patient must be well into the chronic stage of wound healing, and tissue equilibrium must have returned. Enough time must have elapsed to allow softening of the tissues such that all of the edema and induration have resolved and the tissues have regained their normal mobility over the underlying muscle structures. This analysis requires surgical judgment that is routine for the experienced plastic surgeon.

The patient’s health should be optimal from both a physical and psychologic standpoint. Factors that affect wound healing must be optimized. This includes the nutritional status, and perhaps most importantly the smoking history. I strongly believe that cigarette smoking has a deleterious effect on wound healing and scar formation everywhere in the body and must be eliminated before proceeding with surgery. Of course the patient must be in good health and any significant medical conditions or problems (e.g., hypertension) must be well managed.

The surgeon must be optimally prepared as well. This includes having a detailed understanding of the
specific facts about the previous surgical procedures, most importantly including previous incisions and their consequences, implant types and positions, mammographic findings, and pathology reports where pertinent.

In almost every situation the best outcomes from reoperative surgery occur when both the patient and the surgeon are optimally prepared for the surgical reintervention.

Photographic documentation is very helpful in my plastic surgery practice. It is the optimal way of allowing me to analyze and plan plastic surgery procedures. At times there are subtleties that I will pick up during my study of photographs (or sometimes even while looking through the viewfinder in my camera) that have eluded me during the physical examination. More important, the patient can learn a great deal from seeing photographs of herself, especially if they are displayed in a full-page (8− × 10-inch) format.

Photographs of the breasts should be taken in standard positions with the patient standing in a relaxed posture with the arms either at the side or crossed gently behind the back. These positions should always include anteroposterior (AP), lateral, and oblique views. They should include both shoulders and extend from the lower neck to the waist region. Occasionally a view from above with an overhead camera or taken from the top of an examination table or bed with the patient lying supine may be helpful. Occasionally a view from the foot of the bed can be enlightening, especially for problems relating to implant position or malposition (Chapter 3). The view from above sometimes provides insight for the surgeon in that it is the way the patient perceives her breast in a bra or a bathing suit.

In the past I have used 35-mm transparencies (slide photographs) and Polaroid pictures. I currently use digital imaging. This allows me to store all of my photographs in one secured location that is backed up to a second secured site on a larger network. Such imaging permits me to print a black and white 8− × 10-inch photograph of each patient, which is kept in her chart. This is a ready reference in that the patient can see what we started with in cases involving a staged reconstruction.

The format is not as important as is the use of standard photography. As noted, the picture should be taken with the patient in the upright position with her arms in normal posture and with the patient in a relaxed state. Set distances from the subjects are employed and images should be cropped the same way when taking the original photographs. I find that it is helpful to visualize the shoulders, and minimal amount of lower neck anatomy should be included along with a view of the upper abdomen. There should be a small amount of space on either side of the arm. I find it very helpful to have the same background color and lighting conditions for each picture. Obviously anything that can identify the patient (such as parts of the face) should not be included in photographs. Maintaining patient confidentiality is important.

When I see a patient in consultation who has been operated on previously by a different surgeon, I will often ask if she has, or can obtain, copies or her preoperative photographs. Such photographs often provide a valuable reference in that they give me an understanding of her original breast appearance and condition of her tissues, along with insight into the actual changes that have occurred in her breasts.