- Surgeons handling secondary mammaplasties must be able to perform capsulotomy, capsulectomy and capsulorrhaphy
- Blood supply issues, scarring, thinned tissue present challenges
As more and more women undergo aesthetic breast surgery, the number of patients seeking revision mammaplasty is inevitably increasing. Indisputably, the secondary surgeries are typically much more challenging and risky than a primary procedure. In part because of those issues, however, achieving successful outcomes and satisfied patients after revisional surgery is particularly rewarding, says Angelo Cuzalina, M.D., D.D.S.
Breast surgery is a major component of Dr. Cuzalina's practice in Tulsa, Okla., and his case volume has evolved to where he currently performs more revision procedures and simultaneous lifts with augmentation than primary mammaplasties. The complexity of these cases varies widely, he says, from relatively straightforward procedures (such as implant exchange early after augmentation) to much more complicated scenarios. The latter would include postaugmentation cases in which the patient has had multiple previous revisions performed by several different surgeons, developed symmastia or experienced rupture of an older silicone gel implant. With appropriate skills, surgeons can be well-equipped to handle the spectrum of situations that present for revisional breast surgery, says Dr. Cuzalina, president of the American Academy of Cosmetic Surgery and chairman of a cosmetic surgery fellowship program in Tulsa.
A 31-year-old patient with severe pectus carinatum who had 1,150 cc implants placed previously in a subpectoral position, that postpregnancy left her breasts soft, severely ptotic with a major V-shaped chest-walled deformity. She is shown before (left) and six months after superomedial capsulotomies, inferolateral capsulorraphies and simultaneous vertical mastopexies.
"Whether you are handling complications in your own patient or in someone who was operated on by another surgeon, you must be able to perform capsulotomy, capsulectomy and capsulorrhaphy, as well as know when and how to use autologous graft materials," Dr. Cuzalina says.
"Use of tissue matrices, such as acellular human dermal matrixes (AlloDerm, Strattice or LifeCell) and ePTFE (Gore-Tex), in breast revision surgery is a relatively recent development. However, these materials have proven themselves to be very helpful for improving contour irregularities and for overcoming the challenges associated with thinned and scarred tissues in the most complex cases," he says.
A 43-year-old patient with prior periareolar lift and augmentation with severe capsular contracture and extremely thin skin before (left) and three months after partial capsulectomy, implant removal and replacement, along with vertical mastopexy and placement of silicone gel breast implants in a partial submuscular position using an acellular dermal matrix positioned where damaged muscle was nonrepairable. (Photos credit: Angelo Cuzalina, M.D., D.D.S.)