How we judge the success or failure of something is sometimes unclear. This is especially true when it comes to breast reconstructions. In some cases, the surgeon may see things that can be improved, but the patient is quite satisfied. On the other hand, there are times when the patient may feel residual asymmetry or have areas of concern, but if these problems are subtle, they may escape the eye of the surgeon. In the end, the patient’s perception of their outcome is probably the most important consideration.
Many of the studies published in the plastic surgery literature that looks at the outcomes of breast reconstruction surgeries focus on re-operation rates. Therefore, they only assume a reconstruction did not succeed if the patient ultimately had to have additional operations to fix or change the initial reconstruction. In my opinion, these types of endpoints do not capture the patients who are dissatisfied with their reconstructions and may not be aware of options to improve their outcomes.
In our practice, we see many patients for second opinions on existing reconstructions. Many of these patients had initial results that were quite satisfactory but changed significantly due to several factors, such as aging, radiation therapy, weight gain or loss, and complications such as capsular contracture or infection. In other cases, patients state that even though each step of their reconstruction “succeeded,” they never felt that their reconstructed breasts were symmetrical or the volume they desired. While there is no rubber stamp to mend these complaints, options to improve symmetry are often available.
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The most common corrective or revision cases we see in our practice are the implant reconstructions that went on to be treated with radiation therapy. The plastic surgery literature contains several studies that have tried to evaluate the occurrence of complications in this setting, but the outcomes have been quite variable between studies. The take-home message is that in some cases, radiation therapy may not have a very significant effect on reconstruction, but in many cases, it can produce scarring of the tissues that lead to capsular contracture around the implant, pain, asymmetry, deformity, and possible failure of the reconstruction altogether.
Conversion of the implant reconstruction to a natural tissue reconstruction (usually with DIEP flaps) is the most common method we use to improve an unsatisfactory or failed implant reconstruction that occurs after radiation therapy or infection. If radiation therapy was involved, it is generally best to wait several months after the radiation therapy has been completed before the revision surgery is done. This gives the scarring process (fibrosis) that may be triggered by radiation therapy ample time to subside. For cases that either have acute or chronic infection issues, we generally recommend that the implant be removed and a period of rest take place before any corrective or revision flap-based surgeries are attempted. This gives the body a chance to clear the infection and the opportunity for the associated inflammatory response in the tissues to resolve.
While every surgical procedure has the potential to improve or cure a problem, this can often overshadow the fact that every surgical procedure also has an associated set of risks. It is important to always consider the potential benefits and risks when undergoing surgery, especially an elective procedure such as breast reconstruction. If problems, such as scarring, pain, asymmetry, or deformity of the reconstructed breast do occur, there may be ways to improve these issues. See a plastic surgeon certified by the American Board of Plastic Surgery who specializes in and focuses on advanced breast reconstructive procedures to find out what options might be best for you.
