Revisional breast surgery implies a repeat operation

The surgical use of the word “revision” implies more than repeat; it means going back to the site of a previous operation and performing another one, similar perhaps but not necessarily the same. The reasons are multiple – there may have been an anticipated or unanticipated complication, the patient may not be satisfied with a cosmetic result although there is no other issue, the procedure may need to be repeated because the implant has become worn or damaged (not only breasts, applies to pacemakers and eye lens implants).

In terms of revision of breast surgery, the patient may be dissatisfied with a poor result, or perfectly satisfied but now wants the breasts made larger or smaller; something may have happened to the prosthesis and it needs to be replaced; the prosthesis may not have changed but the patient wants a different type (switch from saline to gel); there may have been post-augmentation changes due to pregnancy, weight gain or loss, or advancing age.

If the patient is dissatisfied with her previous surgeon, although she may have very good reasons, the surgeon to whom she now goes must assure themself that (s)he will not be added to the list of unsatisfactory care providers.

Prostheses cannot be expected to serve the full life of the patient, ten years is the usual duration of the manufacturer’s warranty; the patient must be made aware at the time of first implant that one or more later revisions are probable. It is possible that the patient who is now several years older than at the time of her first surgery, is content to accept the natural breast with implant removed, but might be in need of a breast lift.

A capsule of fibrous tissue is certainly going to form around the inserted prosthesis; this may be slight or it may become dense, contracted and distort the prosthesis and breast as well as having an unpleasing sensation to the touch. The degree of encapsulation is graded from Grade1 which looks and feels normal, Grade 2 is firm to the touch, Grade 3 shows slight distortion, and Grade 4 is markedly distorted and possibly painful.

When an encapsulation requires treatment this may be by closed or open methods. The “closed” and no longer recommended one is a manual squeezing of the prosthesis to break the capsule; it is painful, often doesn’t break the capsule but sometimes does break the prosthesis.

The open operations are capsulotomy when the capsule is incised, or capsulectomy when it is excised. If there is one thing we all agree on about fibrous tissue, effectively scar, it will certainly return, only more of it the next time. A capsulectomy therefore often mandates reposition of the prosthesis in relation to the pectoralis major, on top or beneath, whichever is the opposite of the original position.