Introduction

Breast reduction is a popular procedure worldwide. It most often results in relief of the presenting symptoms in the patients seeking it. The postoperative appearance of the breasts is generally improved since they are uplifted and re-shaped from the standpoint of improved projection and the manner in which they relate to the torso of a given patient. Therefore in a real sense, the operation is both a functional and cosmetic procedure. The vast majority of patients who experience relief from their macromastia symptoms will readily accept the “trade-off” of “scars for shape”.

Revision surgery following a breast reduction has been relatively uncommon in the author’s practice experience over the past 25 years – probably in the range of 2–3%. The main reasons patients seek or have revision surgery at various time points in the wound healing continuum are listed under the headings of sub-acute and long-term complications of breast reduction, listed in Table 9.1.

Table 9.1 Complications of breast reduction

This chapter focuses on the conditions listed under the long-term complications section. It also comments on two acute complications, namely hematoma and nipple areola ischemia, since these complications should be addressed acutely and require revision of the original surgical procedure.

Patient history

The history, biologic processes related to wound healing, postoperative management and potential complications should be carefully reviewed with every patient undergoing a surgical procedure. These elements of patient care are of critical importance in being considered for elective reoperative or revision surgery, including revision of breast reduction, and revision of mastopexy. There is significant overlap of these elements for these two procedures, which must be sought out by the plastic surgeon, analyzed, and discussed with the patient prior to any revisional surgery procedure. Because of this overlap, these elements are presented here prior to describing the specific conditions noted below.

The revision of augmentation-mastopexy entails the additional element of a breast implant, which has its own particular set of potential complications and inherent risks (capsular contracture, implant failure, and unplanned additional surgery considerations), which must also be discussed with the patient prior to a revision procedure.

The history is an extremely important element of the patient evaluation in all cases of revision breast reduction, mastopexy and augmentation mastopexy. It is a critical determinant of whether to reoperate (a patient may have a problem which can be improved by surgery or unrealistic expectations for improvement) or when to reoperate. The latter is determined by a satisfactory degree of wound healing or the return of softness and suppleness to the tissues of the breast. This wound healing or maturation is influenced by the time elapsed since the previous surgery(ies) and whether the previous procedure resulted in a surgical complication, the nature of the complication and the patient’s recovery. In general, reoperation is best delayed at least 6 months following the previous procedure.

Reoperative surgical procedures in all areas of plastic surgery require an in-depth understanding of the problem from the standpoint of anatomy, aesthetic appearance, concerns of the patient, and as mentioned above, the time which has elapsed relative to the previous procedure(s). Regardless of whether the surgeon is operating to treat a problem in one of his or her own patients or is planning to treat a patient operated on elsewhere, carefully obtaining an accurate history and performing a thorough physical examination is essential.

Particular attention is paid to the patient’s chief complaint. It is critical to understand what she is most bothered by and therefore focus on her chief complaint as much as possible. Is the patient dissatisfied with: the scar appearance; contour problems; asymmetry(ies); nipple areola position or appearance; masses of lumps in the breast; under-reduction with persistence of symptoms; over-reduction; loss of shape, or pain? Is it a combination of these symptoms? A key element of successful revision procedures is to understand what the patient is most bothered by and then to communicate with the patient about what can and cannot be made better.

It is essential that the surgeon planning a reoperative procedure following breast reduction have as precise an understanding as possible about the blood supply to the nipple areola complex, as a revision surgery procedure may entail moving the NAC on a pedicle or altering breast shape adjacent to it.¹ This is also true for revision of mastopexy and augmentation-mastopexy procedures. This information is most accurately obtained from a review of the previous operative record(s). The greatest margin of safety for ensuring nipple areola complex viability is obtained by using the previously developed pedicle. In patients you are evaluating after surgery performed elsewhere, these records can be obtained by asking the patient to request them in writing from the previous surgeon. In most US states, the law requires that permission must be given by the patient before you can speak with the previous surgeon.

It is important to comment on breast pain following previous surgery. Mastodynia or pain in the breast is multifactorial in etiology and moreover, the exact cause is often not possible to identify, especially when scars have been added to the various etiologies. Moreover the author’s experience has shown that it is most often not possible to completely cure such pain with a scalpel. Therefore no guarantees should be made about pain relief in virtually any circumstance. Instead, inform each patient that their pain may be unchanged, may be made better, or may even be made worse by a revision surgery procedure.

Preoperative patient evaluation

Basic science

The basic science/wound healing elements relate to the condition of the breast tissue, which includes skin and parenchymal tissue elasticity, degree of scar tissue present and maturation of scar. The surgeon must pay particular attention to the mobility of the skin over the underlying tissue and the softness and distensibility of scar or lack thereof.

Postoperative management

The postoperative management includes appropriate perioperative pain medication, antibiotic therapy, along with drain placement and care. The patient and their family should be instructed in how to manage the suction drains, and a system of communication between the surgeon’s office and the patient regarding 24 h drain output should be set in place.

All patients are asked to refrain from vigorous physical exertion (high impact activity and anything that causes their breast to bounce) for at least a month following surgery. This includes running, especially running on a treadmill. In an attempt to support the breast during the acute and sub-acute phase of internal wound healing patients should wear a “snug fitting” sports bra for support of their breasts on a 24 h a day basis for 4–6 weeks following surgery.

Patients’ questions received by telephone should be answered promptly when they have concerns about potential healing issues. This makes the patient feel better and builds on the trust that began in the preoperative period.

Outcomes/prognosis/complications

The potential risks and complications of the revision surgery should be thoroughly reviewed with the patient preoperatively. The author has adopted a standardized approach reviewing the wound healing issues and cosmetic issues related to each procedure under these specific headings. These explanations are reflected in the typed office consent document, which the patient reviews and signs at the time of these explanations, confirming her receipt of this information. Highlights of the patient–doctor routine discussions are outlined below.

Wound healing is not completely predictable following surgery, especially in revision procedures. Unanticipated wound separation, open wounds, prolonged time to healing of these wounds and sub-optimal scarring occurs. Patients need to be aware of this – especially patients who have sustained a similar complication in the past. It has been established that wound healing in all fields of surgery is negatively impacted by cigarette smoking. For this reason, the author will not perform elective plastic surgery procedures involving skin elevation, flap advancement and skin tightening at the line of closure (often exactly what is entailed in revision breast reduction, revision mastopexy, and revision augmentation mastopexy) in patients who smoke. Loss of sensation in the skin or NAC is possible in all cases of breast surgery especially when the NAC is being moved. As noted previously, relief of pain by surgical intervention almost never completely occurs and this is explained to the patient and their family or other support team preoperatively. It is important to repeat this several times during a consultation and document that the patient has been told about this.

A discussion of complications is also important. It is best to convert this to a time for informing and teaching the patient, explaining what may be done to minimize the likelihood of unwanted events. The patient’s questions must be addressed and answered to the best of the surgeon’s knowledge. The patient should be issued with a copy of the informed consent document to take home to read, and she should discuss it with their family and support team. They should be informed that they can call the surgeon with any questions that they may have regarding anything in the consent or anything discussed during the consultation.

The surgeon should outline and disclose to the patient in writing, his or her policy for unplanned additional surgery from the standpoint of professional fees, facility fees, and fees for ancillary services (e.g., anesthesia). This should be outlined for unplanned surgical intervention in the acute postoperative period (e.g., drainage of a hematoma following a procedure) or for long-term sequelae (recurrent breast ptosis). Making sure that patients understand this uncommon but potential reality is important.

Finally, an overall aesthetic improvement, while expected and realized in most cases, can never be guaranteed. This arena of revision for significant problems following breast reduction, mastopexy, and augmentation mastopexy is one where it is best for the plastic surgeon to “under promise but over deliver.”

Surgical re-intervention for acute problems

Hematoma

Reoperation in this setting is relatively rare. It mainly entails drainage of hematomas when they occur. The hematoma rate is ≤1–2%. It is marked by swelling, ecchymosis, and pain. It can occur at any location in the breast. For localized, nonexpanding and liquefied hematoma problems, a percutaneous aspiration may suffice (Fig. 9.1). It is essential to aspirate or drain hematomas since they may threaten the viability of the overlying skin³ and/or result in long-term palpable abnormalities and asymmetries in the breast(s). Any existing coagulopathies that may not have been identified preoperatively (e.g., von Willebrand’s disease⁴) must be sought and corrected.

Fig. 9.1 Aspiration of liquefied hematoma in lateral aspect of breast on postoperative day 10.

For situations where the process is more diffuse or the hematoma may be expanding, re-exploration is often indicated. Re-opening the incisions provides excellent access to the entire operative field. Most commonly, a defined bleeding point is not found with the exception of large branches from the internal mammary or external mammary (lateral thoracic) arteries. The wound is copiously irrigated and a drain is inserted.

Wound excision and re-closure

Unattractive scarring is probably the most common adverse consequence of breast reduction. The problem is most commonly related to scar hypertrophy or to a wide depressed scar after skin loss noted during the acute and sub-acute phases of wound healing. Both can be improved by a well-timed and properly executed wound excision and re-closure.

Scars all go through a life cycle. In general, they appear more favorable as time passes. Therefore it is preferable not to perform any type of scar revision surgery for at least 1 year following surgery. In the case of significant scar hypertrophy, especially laterally after a Wise pattern incision, the intra-scar injection of Kenalog 10 mg/mL mixed with 1% Xylocaine is helpful. The author performs a single injection and then allows 3 months to elapse before performing an additional injection if requested. It must be borne in mind that color changes in the scars, especially hypo-pigmentation are not uncommon with this approach. In addition, injections should be into the scar itself and not into the subcutaneous tissue. Injecting the subcutaneous tissue will cause tissue atrophy and can produce a “sunken appearance” of the scars.

If after a year the patient has significantly spread scars, and other conditions are favorable, then a scar excision and re-closure is an option. It should be carefully explained to the patient that a definite improvement in the scar condition cannot be guaranteed. The keys to perform this type of approach would be to excise through the skin at a right angle. Excise tissue deep to the scar and limit the actual undermining of the skin tissue. A layered closure of the wound with a coated polyglycolic acid suture (4-0 PDS) with buried knots is the author’s suture of choice and has not routinely used the permanent suture in this situation, although some surgeons feel that it may confer an advantage in terms of long-term maintenance of a narrower scar. The author recommends that patients apply paper tape to their wounds. Although this has not been studied in a scientifically, it appears that it has some benefit. This is continued for 3 months. Subsequent to this, scar massage is performed twice a day, along with the topical application of vitamin E cream.

Contour abnormalities at the end of incisions

Contour abnormalities at the end of incision probably represent the most common reoperative procedure performed in patients seeking additional surgery following breast reduction. These excisions can be performed in an office setting as an outpatient. These “dog-ears” can be addressed in the operating room at the end of the procedure if they appear at the end of the wound closure. If they are not addressed at this stage, then they can be addressed in the office as a brief outpatient surgical operation.

Nipple areola ischemia

Ischemia of the NAC is a dreaded but fortunately rare potential complication of every pedicled breast reduction procedure (probably in the range of 1%). It is most often related to arterial insufficiency, and it usually occurs in the setting of a large breast reduction (>1000 g resection), where a long pedicle is created to carry the circulation to the NAC, often with associated co-morbidities such as obesity and diabetes mellitus.² Folding such a pedicle during closure additionally stresses the circulation. Therefore, in cases where NAC is suspected, the incision should be opened and the pedicle examined. If it is too bulky, it should be reduced in volume and the circulation re-evaluated. If this improves the situation, then re-closure of the wounds is attempted. If re-closure again causes a decrease in circulation, the pedicle might be trimmed further, the skin flaps might be made thinner, or some of the incisions may be left open.

If this still does not adequately address the problem, then consideration is given to removing the nipple from its position on the pedicle, resecting the distal pedicle, and applying the nipple as a full thickness skin graft more proximally on the pedicle itself (Fig. 9.2C,D)

Related posts:

Technology innovation in plastic surgery Cleft and craniofacial orthognathic surgery Managing the cosmetic patient TMJ dysfunction and obstructive sleep apnea Fractures and dislocations of the wrist and distal radius Facial transplant

Stay updated, free articles. Join our Telegram channel

Join