By its very nature, breast reconstruction is often a staged procedure requiring two, three, or more steps over a period of many months to achieve a successful outcome. The necessary components include creating a breast mound, achieving symmetry, reconstructing the nipple, and permanently coloring the nipple and areola. Along this path of reconstruction, the surgeon also has the opportunity to revise or revisit earlier phases of the reconstruction process even as the next stage is being undertaken. When talking to patients, we often liken breast reconstruction to a sculpture or an oil painting, where it is well accepted that repeated refinements are necessary to achieve something worthwhile. The episodic popularity of one-stage breast reconstruction, although valid in the occasional patient, is worrisome because of its implication that consistent results can or should be achieved in one step. As more patients choose prophylactic surgery, and as implants and reconstructive techniques improve, the expectations of some patients have risen to near the level of cosmetic surgery. While this is not always realistic, we are frequently able to deliver excellent results, sometimes through multiple refinements. While this chapter focuses on reconstructive cases, the same techniques can frequently be applied to any secondary implant case. The figures in this chapter illustrate our most frequently used techniques, and frequently multiple techniques are used in each patient.

Whether completing the prosthetic breast reconstruction of one’s patient or inheriting that of another surgeon, the second or later stages in prosthetic breast reconstruction are often the most challenging and complex. This chapter focuses on common problems seen in patients during or after breast reconstruction using breast implants. Common problems include capsular contracture around the implant or expander, implant malposition, inframammary fold malposition or absence, inadequate or malpositioned nipple-areola reconstruction, and implant problems such as rupture, rippling, and improper size or shape. Management of these patients includes proper diagnosis of the problem(s) and planning of the necessary steps for correction.

If the problem is simply device deflation or rupture, then the solution is straightforward. Recreation of the inframammary fold is discussed as a separate issue in Chapters 41 and 42. This chapter thus concentrates on capsular contracture, nipple-areola problems, device problems (such as malposition, rippling, and improper implant selection), and tissue coverage and contour problems. When evaluating these patients, it is important to review the previous operative records and the current physical findings. In assessing each patient, there are several issues to consider:

In determining whether an implant reconstruction is currently an appropriate option, the tissue quality and history of infection or radiation are important factors. Radiation is one of the most common factors compromising tissue quality in implant reconstruction. Less commonly, infection can damage tissue and render it unsuitable to accommodate an implant. Recurrent infection can also make an implant reconstruction untenable. For a more in-depth discussion of the risks of implant reconstruction in the setting of radiation, refer to Chapter 49 on prosthetic reconstruction in the radiated breast.