Breast augmentation revisions require careful presurgical consultations

The basic elements of a preoperative consultation for a woman seeking surgical revision after breast augmentation are the same as for any cosmetic procedure. Obtaining a good history, performing a careful clinical examination and identifying the patient's concerns and goals remain fundamental for designing a surgical plan that can deliver a satisfactory result.

Just as revisional surgery after breast augmentation is typically more complex than a primary procedure, however, so, too, is the preoperative consultation, say plastic surgeons who specialize in breast augmentation.

Among these challenges is the fact that the population of patients who present for revisional surgery after breast augmentation spans a broad spectrum, particularly with respect to the diversity of their motivations and the interval elapsed since their primary surgery. Furthermore, additional surgery may be required because of anatomical changes caused by the previous procedure (or that have occurred over time), and this information must be explained to and understood by patients who may be expecting an easy fix. Surgeons also may face the challenge of communicating with a dissatisfied and angry patient. Nevertheless, in-depth and honest discussions outlining the pros, cons and costs of the various options remain the foundation for ultimately achieving success.

"A woman in her mid 40s who had implant surgery as a teenager 25 years ago will present with different personal concerns and anatomical issues than someone who had primary surgery a year ago and was never happy with the outcome," says Michael Brown, M.D., a board-certified plastic surgeon in Ashburn, Va.

"Therefore, listening to the patient to understand why she is seeking a revision is one of the most important things the surgeon can do. While surgeons might develop their own notions based on the history and clinical exam, it's impossible to know a woman's motivations and satisfy her goals unless she is allowed to explain her concerns," he says.

Dr. Edwards

A patient who had large saline implants placed above the muscle (left) was unhappy with the ripples and visibility of the implant. The patient is shown two years after secondary surgery (right), which involved moving the implant to a partially submuscular pocket and performing a mastopexy over smaller silicone gel implants. (Photos credit: Michael C. Edwards, M.D., F.A.C.S.)

Dr. Edwards notes that he draws a lot of diagrams to explain the various techniques and presents pictures of previous patients. "Patients may be more educated today than ever, but they are not physicians," he says. "Women may need a mastopexy and won't know what that involves or be horrified by their perceptions about the risk of scarring. Some women may be looking for a change in implant size and think the revision surgery is a simple exchange operation, not realizing it can involve additional elements because of vascular and soft tissue changes associated with their earlier procedure."

Dr. Brown says he also relies heavily on photographs and maintains a library of images that are catalogued by physical attributes, rather than by implant volume or bra size.

"Concentrating on the latter numbers instead of simply focusing on actual results can cause women to get lost and be misled. It is much better to use pictures in a way that helps them understand their specific anatomic situation and how their appearance can be improved," Dr. Brown says.

Dr. Brown

Dr. Maxwell

G. Patrick Maxwell, M.D., a board-certified plastic surgeon in Nashville, Tenn., agrees. For example, combined augmentation and mastopexy may be needed to satisfy the woman's goals. Innovative surgical techniques, including creation of a "neopocket" for implant placement along with use of regenerative matrices (acellular dermal matrix, ADM), fat grafting and/or a new implant may also be indicated to achieve success. As patients may be reluctant to pay the extra cost for additional techniques and materials, education about their rationale is important, Dr. Maxwell says.

"Certainly, the patient seeking revision augmentation has already paid a significant fee for her first procedure and without expecting to have subsequent surgery. However, revision candidates need to approach the decision-making process with a mind-set of cost-outcome optimization rather than minimization," Dr. Maxwell says. "A well-planned revision including appropriate adjuncts is likely to be cost-saving in the end by decreasing the likelihood of needing yet another operation."

Dr. Brown says he creates a flowchart that details each option and its potential outcomes. One copy is placed in the patient's record, and another is given to the patient to review at home.

"There are a number of different consequences that can occur with secondary procedures, even with a technically flawless procedure, and with all of the options and possible outcomes to consider, patients cannot possibly remember everything they are told in the office. Providing patients with this written information can help them arrive at an informed decision and choose an operation that will deliver satisfactory results," Dr. Brown says.

He says with cost to the patient in mind, he encourages women who are dissatisfied after a recent primary surgery to try to rectify the situation by returning to their previous surgeon. Nevertheless, he recognizes that that approach may not be viable if poor surgeon-patient communication from the outset is the cause for a suboptimal outcome, and the reason why the patient is seeking another's expertise.