Revision Breast Surgery

With so many breast augmentations being performed around the country, I have seen a dramatic increase in the number of women coming to see me for repair of suboptimal results. Many women who have undergone surgery with other surgeons and are unhappy with the appearance of their breast augmentation come to Scottsdale to consult with me for revision surgery. Sometimes the problems are simply due to changes in the breasts from time, weight fluctuations or pregnancies. Other times, the original surgeon did not meet the patient’s expectations with regard to shape, size or symmetry. Although breast revision surgery can be extremely challenging, I am usually able to significantly improve the appearance of the breasts and achieve more natural and beautiful results.

A number of techniques can be used to improve the appearance of breasts. These techniques include altering the placement of the implant from over to under the muscle, changing the size or type of implant and creating a better pocket to accommodate the implant. In addition, procedures to help minimize the appearance of scars or alter the size and shape of the nipples can help significantly with breast aesthetics. Finally, the addition of an acellular dermal matrix such as Strattice™ can provide soft-tissue support to help with implant positioning and reduce the chance of rippling and capsular contracture.

Tuberous Breast Surgery

“Tuberous” breasts are caused by congenital tightness of the lower breast skin that restricts breast growth during development and forces the breast tissue to protrude through the areolas. As a result, tuberous breasts tend to be widely spaced, droopy and have a pointy appearance. Often, the pigmented skin around the nipples appears puffy and larger than normal. Because of the high location of the breast crease and tight skin, the breasts often appear to be long and narrow rather than having the more common rounded shape.

Tuberous breasts fall along a spectrum, with some cases being much more severe than others. All tuberous breast cases present challenges that are not generally seen with standard breast augmentation surgeries. A number of techniques are available for correcting tuberous breasts, so the procedure can be personalized to meet each patient’s specific needs. Typically, when I do tuberous breast surgery for women as part of their breast augmentation in the Scottsdale area, I try to create a lower, more natural breast crease. This allows the lower half of the breast to expand over time and creates a rounder breast shape after an implant is placed. After the inframammary fold (the crease under the breast) is lowered and the implant size is selected, I usually perform a circumareolar mastopexy, which is a tightening around the areola. This allows me to reduce the areola size and puffiness while simultaneously changing the breast from a pointy shape to a rounder shape.

Nipple/Areolar Surgery

Women sometimes want to correct multiple aspects of their breasts during enhancement procedures. For my Phoenix patients, breast augmentation is a great way to increase breast volume, but there may be other concerns, such as the appearance of the nipple and areola. Nipple and areola surgery often can help create a more aesthetic breast appearance.

• Nipple surgery can correct nipples that are too large, droopy or inverted. Although nipple inversion correction can affect breastfeeding, nipple reduction generally has no effect on breastfeeding. Normal sensation is usually maintained with these surgeries, as well.
• Areola reduction surgery starts with an incision around the border of the areola to reduce the diameter. The same incision can be used to remove some underlying breast tissue if the areola appears puffy or swollen. Since the incision is placed where the skin color changes along the border of the areola, most patients find that the scars are less noticeable because they blend along the natural color junction.

There are certainly some very talented surgeons in Mexico, South America and elsewhere, but the degree of oversight and regulations pales in comparison to the U.S. Surgery is not just about the plastic surgeon – for Scottsdale residents, it is also about the ancillary staff, as well as accreditation, medications and devices used during surgery. In the U.S., very stringent rules and regulations are in place to protect patient safety. The FDA provides important oversight to ensure that medications and products used during surgery have been studied and tested properly.

Recently in the news, there have been reports of concern with a particular type of implant manufactured in France by a now-defunct company called Poly Implants Prothèses (PIP). In 2006, I was involved in a study demonstrating the high deflation rate of saline implants produced by PIP, which was published in Plastic and Reconstructive Surgery, the most prestigious journal for plastic surgeons. In this article, we advised that the deflation rate with these implants was much higher than with saline implants produced by Mentor® and Allergan, the U.S. implant manufacturers.

More recently, it has come to light that the silicone implants produced by this company were made using industrial-grade rather than medical-grade silicone. Of course, this cut the cost on implants significantly, but it also cut major corners on safety. Now, many women are reporting concerns with their implants and tens of thousands of women all over the world may be advised to have these implants removed and exchanged.

Thankfully, because the FDA never approved these implants, the only American women who have to worry are those who travelled abroad for surgery and received PIP silicone implants. Unlike Mentor and Allergan silicone implants, which are considered the most studied medical devices in medical history, PIP implants did not have to undergo rigorous safety screening by the FDA. As a result, patients will have to endure extra surgery to deal with the failure of PIP to produce a quality medical product.

This situation should serve as a warning to patients: Cutting costs up front may end up costing more in the long run. Although surgery in the U.S. is generally more expensive than in other countries, this cost covers more than surgery alone. It covers additional safety and quality and, ultimately for patients, peace of mind.

First and foremost, genetics is the greatest uncontrollable factor. Everyone scars differently. The same surgeon can perform the same surgery using the same technique on two different patients and get completely different scars. Simply put, some people heal more smoothly, while others have a tendency to form more noticeable scars.

Patients who have a personal or family history of bad scarring should be cautious about surgery. A genetic tendency toward severe scarring can affect not only the external, visible scar tissue but also the internal scar tissue.

Many people of Asian, African, Middle Eastern and Mediterranean descent are more prone to scarring. However, these are general findings, and every individual heals differently regardless of his or her ethnicity. Some Caucasians form thick, red scars while some African-Americans form nearly invisible scars.

Another factor affecting scarring is body location. Certain areas of the body tend to heal with thicker scars. The center of the chest, the shoulders and the back are notorious for bad scars because of the thick, tight skin. This is why surgeons try to avoid incisions in these areas. If, for some reason, an incision must be made in one of these areas, there is a higher risk for thicker or more noticeable scars.

Tension on a wound closure also can contribute to scarring. The more the skin is being pulled, the higher the likelihood that the patient will develop a bad scar. This is one reason why plastic surgery is so challenging; almost everything we do requires tension. Unlike a C-section or an appendectomy, where no skin is removed, breast reductions, tummy tucks and facelifts all require skin removal, which causes more tension to be placed on the wound closure.

To counteract this, plastic surgeons pay a lot of attention to layered closure and fine suturing techniques. One could argue that tension is a controllable factor. However, to a large degree, the surgeon cannot control tension. To achieve the desired result, a certain amount of tightening is required with procedures such as a breast lift or a tummy tuck in the Phoenix area.

Some other causes of scarring also cannot be fully controlled. These include wound infections, problems dissolving internal sutures and other healing challenges. If one of these problems occurs, the patient and surgeon can work together to improve the situation.

I hope I have helped explain one of the most unpredictable and important aspects of plastic surgery. I always do everything I can, both during and after surgery, to minimize scars. Most of my patients heal extremely well and are happy with their results, including their minimal scars. Although some people will develop less than ideal scars despite my best efforts, the majority of such patients are still happy with the overall results of their surgery.

The bottom line is that everyone considering elective surgery must be realistic about the possibility of having more visible scars than they would like and understand that this is a low – but real – risk.

Obviously, scars will be a concern for patients having extensive surgery, such as a tummy tuck or a breast lift, but patients having less invasive surgery, such as liposuction or breast augmentation, still worry about their scars.

The truth about scars is that there are some aspects the surgeon can control, while other aspects cannot be controlled. Keeping that in mind, the first part of this two-part blog series will discuss the controllable factors, and the second part will discuss the uncontrollable ones.

Controllable factors mostly have to do with surgical technique and postoperative care. During surgery, it is important for the surgeon to be as gentle as possible with the tissues. Rough handling of the skin, overuse of cauterization and imprecise incisions can certainly cause extra scarring. In addition, poor suturing techniques, the types of sutures used and how carefully the sutures are placed can affect scar healing.

When I perform a procedure such as a tummy tuck in the Phoenix area, I am extremely meticulous about how I handle tissue in order to cause the least amount of trauma possible. I also take time during the closure to make sure the tissues and skin line up as cleanly and smoothly as possible. Finally, for all but the smallest surgeries, I do multiple layers of suturing with dissolving, under-the-skin sutures to avoid any stitch marks in the skin. I use longer-lasting deep sutures to take tension off the skin-surface sutures, which reduces the possibility of scar spread.

Controllable factors after surgery include minimizing the risk of infection, scar massage, using ointment in the early period and using silicone sheeting or steroid injections if necessary to flatten scars. For my patients’ follow-up visits after surgery, I always see them personally to evaluate the scars and advise them on what can be done to minimize the visibility of scars.

It’s important to understand that scars fade over time. As you heal, your scars will become less visible.

One final idea I would like to share is that patients can take part in their own healing process to minimize scars. It is very important to follow post-op instructions, including these recommendations:

• Do not exercise too soon. This can put strain on the tissues.
• Avoid smoking after surgery. Smoking impairs wound healing.
• Avoid UV exposure or tanning of scar areas for a full year to minimize scar darkening.
• Massage your scars for a few minutes each day to help them soften. Products such as Mederma®, which are marketed specifically for reducing scars and stretch marks, are fine, but studies have not shown a huge improvement in long-term scarring. If patients want to use these products, I do not discourage them as long as I know exactly what they are putting on their scars. Some products, such as topical vitamin E, have been shown to cause more harm than good.

In Part 2 of this blog series, I will discuss factors related to scarring that are outside our control.

As seen by the ever-growing number of Mommy Makeover patients at my plastic surgery office near Phoenix , more and more women are ready to look and feel their best after having kids.  Additionally, these women are busy with so many things that they want to get multiple surgeries done simultaneously in order to minimize recovery time and time off work.

While combining breast surgery and abdominoplasty has been shown to be safe (a topic I have researched and presented extensively in plastic surgery journals), not all combination surgeries are appropriate.

Patients will frequently call my office to ask if I can combine a tummy tuck with a planned C-section.  While the idea of having a child and leaving the hospital with a flatter, tighter abdomen is appealing, this is a bad idea for multiple reasons.

Abdominoplasty is major surgery that should be performed on patients when they are in peak health and are on a good diet and exercise program in order to get the best results. At the end of a pregnancy, most women are nutritionally depleted, as so much of their energy is going to support their developing baby.  Also, many women are sleep deprived and physically exhausted by the long pregnancy. This is not an ideal time to perform an elective surgery.

Additionally, at the end of pregnancy, women are very edematous (swollen), and the abdominal skin and connective tissue is very stretched out.  It can often take women 6 to 12 months to return to a normal baseline weight and tightness. This is the appropriate time to perform a tummy tuck in order to get the best result.

Finally, during a C-section, the baby is delivered through an abdominal incision. This is accompanied by amniotic fluid, and possible meconium (stool from the baby).  It is important when performing an abdominoplasty to have a sterile surgical field, and this would be severely compromised by the fluids in the uterus.

Although convenience is important, safety and good results are much more critical. This is why I always recommend that patients undergoing a C-section allow themselves to heal, recover nutritionally and get in the best shape possible after their delivery before they consider abdominoplasty surgery.  If the proper precautions are taken, I can achieve the best, most aesthetic results in the safest way possible.