REVISION BREAST RECONSTRUCTION SURGERY

Breast cancer is the commonest type of cancer in females in Singapore. Many breast cancer patients require a mastectomy in order to completely remove the malignant tumor and miminize the risk of spread and recurrence of the cancer. The consequence of a mastectomy is loss of breast tissue, leading to the need for breast reconstruction to restore the volume and shape of breast. Breast reconstruction is therefore one of the commonest types of reconstructive surgery performed by plastic surgeons.

Due to advanced reconstructive techniques and the availability of high quality breast implants (such as the Motiva Ergonomix implant), it often possible for the plastic surgeon to achieve a breast reconstruction result that closely resembles the appearance of a normal breast. This can be very satisfying for both the patient and surgeon, and significantly restores the patient’s self-image and self-esteem. The affected breast may be reconstructed with a breast implant, the patient’s own tissue (commonly obtained from the back or the abdomen), or a combination of both implant and the patient’s own tissue.

Despite the reconstructive surgeon’s best efforts, the final result of a breast reconstruction may occasionally fall short of ideal standards. Issues that could detract from an ideal result include the following: suboptimal size (too big or too small), contour deformities (uneven contour or contour depressions), visibility of implant edges (due to thinness of tissues and skin), implant malposition (implant in the wrong place, e.g. too far in or too far out), capsular contracture (thickening of the capsule of scar tissue surrounding an implant which makes the implant feel too firm its shape too round), and asymmetry when compared with the opposite breast.

In these situations, a revision breast reconstruction can be considered, and it is usually possible to address these problems so that the ultimate goal of a reconstructed breast of ideal volume and shape s achieved.

If an implant was used to reconstruct the breast, suboptimal size can addressed by upsizing or downsizing the implant. If the patient’s own tissue was used for the reconstruction and the breast is too big, some this tissue can be surgically trimmed off to reduce its size. If on the other hand the reconstructed breast is not big enough, then more volume can be added through fat grafting. Fat grafting involves removing fat cells from other parts of the body using gentle, non-traumatic liposuction technique, purifying the fat, then injecting the purified fat cells carefully and meticulously in small parcels into the areas that need it. This may need to be repeated six months or more later as approximately 30% to 40% of the injected fat cells may not survive, resulting is some loss of the original volume.

The solution to this problem depends somewhat on the cause of the contour problem. If an implant had been used for the reconstruction and there are residual contour irregularities due to uneven loss of soft tissue from the mastectomy, fat grafting is the most effective solution, as it allows the surgeon to selectively inject fat into the various areas of contour depression in the required amounts. This versatility makes fat grafting ideal for situations where different amounts of volume are required in different parts of the reconstructed breast.

If the breast had been reconstructed with the patient’s own tissues, contour problems usually consist of one or more areas being too bulky and hence too prominent, thus preventing the ideal breast shape from being attained. This can be addressed by surgically trimming parts that are too bulky and prominent, producing a smoother contour as a result.

This problem usually occurs in thin patients with thin skin and soft tissue layers. Fat grafting is an effective solution because it allows the plastic surgeon to literally thicken the soft tissues under the skin by adding fat. This results in more soft tissue padding for the implant edges, thus reducing their visibility and making the breast look more natural.

When an implant has been used to reconstruct the breast, it can sometimes end up being in a suboptimal position because the amount of space it was left to fill after the mastectomy was too big. This can occur if the breast surgeon had to surgically dissect laterally and upwards towards the armpit in order to ensure that all breast tissue and accompanying lymph nodes were removed. Although there are technical measures that can be taken to stabilize the implant in the ideal position as much as possible during the recovery period (such as wearing surgical bras and stabilizing bands and tapes), the implant could still drift into a suboptimal position and end up being too close to the midline of the chest or too far laterally to the side.

Implants malposition is best corrected after about six months, when the tissues have completely healed around the implant. The implant is removed and the space it was lying in (known as the implant pocket) is modified by enlarging and reducing it in the appropriate areas. Enlargement is performed by surgical dissection to enlarge to the pocket. Reduction is performed by closing off excessive space with strong stitches. The implant is then replaced into the redesigned pocket.         

Capsular contracture refers to thickening and contraction of the layer of scar tissue that the body produces in response the presence of an implant. The thick, contracting capsule squeezes the implant, resulting in the implant feeling too firm and its shape becoming too round. Certain types of breast implant are more prone to capsular contracture. The Motiva Ergonomix implant has the lowest capsular contracture rate of all implants (about 1%). This is a major reason for it being the preferred choice of implant.

Capsular contracture is best corrected surgically by removing the implant, removing the capsule, then replacing the implant with a Motiva implant.

After a successful breast reconstruction, it may become apparent that the opposite breast looks different from the reconstructed breast in size and/or shape. It may look smaller or larger, it may look saggy (the most common problem with shape), or it may be different in both size and shape.

If the asymmetry is significant and the patient is bothered by it, the opposite breast can be modified by performing a breast reduction (if the opposite breast is larger), a breast augmentation (if the opposite breast is smaller), or a breast lift (if the opposite breast is sagging), or a combination of breast lift and breast size change.  

With careful and thorough preoperative analysis, these potential asymmetries can often be predicted beforehand, and plans to address them can then be made as part of the overall surgical plan and carried out during the same operation as the breast reconstruction to ensure that all issues are efficiently addressed together.

There has been increasing interest and demand for revision breast reconstruction surgery in Singapore due to higher patient expectations as patients become more discerning and knowledgeble about the options available to them. With modern surgical techniques, the availability of the Motiva breast implant and effective fat grafting systems, we are now better equipped to give our breast cancer patients the refined results that they seek for their reconstructed breasts.