Revisions for Complications of Aesthetic Breast Surgery

*Angelo Cuzalina, Pasquale G. Tolomeo and Victoria A. Mañón*

#### **Abstract**

Breast surgery continues to be one of the most sought-after cosmetic procedures in recent years. Patients are opting to undergo various procedures to enhance the aesthetics and appearance of their breasts. The goal of any cosmetic procedure is to compliment one's body and achieve satisfactory results. However, some patients may experience complications or become dissatisfied with the final result. These complications include breast asymmetry, implant malposition, implant deflation, rippling, and capsular contracture. Aesthetic breast revision is a highly specialized procedure that requires an experienced surgeon, aiming to address the patient's concerns as well as achieve a more desirable outcome.

**Keywords:** aesthetic breast surgery, breast revision, implant malposition, capsular contraction, breast mastopexy, breast augmentation

#### **1. Introduction**

Breast surgery is one of the most sought-after cosmetic treatments with breast augmentation being the most common aesthetic procedure [1]. Patients may undergo various procedures to enhance and improve the appearance of their breasts. Breast surgery can be divided into breast augmentation with the use of implants or autologous fat transfer, mastopexy, reduction mammaplasty, or a combination of these procedures. The aesthetic outcomes rely on postoperative breast symmetry, size, and shape. Beauty is in the eye of the beholder, and it is greatly influenced by an individual's perception, as well as symmetrical balance. Aesthetic breast surgery is the congruence of science and art based on the relationship between human morphology and anthropometric proportions.

As with any procedure, there are associated risks with breast surgery including asymmetry, rippling, implant malposition, implant deflation, or capsular contracture. The goal of aesthetic revisional breast surgery is to address the unsatisfactory result or complication of the previous breast surgery and produce an aesthetic result. The benefits of revisional breast surgery are numerous. Patients can achieve a more desirable breast size and shape, correct any complications from previous breast surgery, and improve their self-confidence and body image.

However, revision breast surgery is not without risks. The surgery carries the same risks as other surgical procedures such as bleeding, infection, and anesthesia

complications. The risks of revision surgery are greater than the risks of the initial breast surgery due to the presence of scar tissue, altered anatomy, and compromized blood supply, increasing the risk of tissue/nipple necrosis.

Aesthetic revision breast surgery is a complex procedure that requires a skilled and experienced surgeon to achieve optimal results. Patients should carefully research potential surgeons and choose a surgeon who has extensive experience performing breast revision surgery.

The surgical aspect of breast surgery continues to evolve over time with advancements in surgical techniques and a greater knowledge of anatomy and its variants. The surgeon must have an armamentarium of surgical techniques to offer treatment that promises both aesthetic results and longevity with marginal risk of complications. As the technical aspect of surgery improves, knowledge of the anatomy is the single aspect of breast surgery that remains consistent. Being equipped with this knowledge allows the surgeon to identify and preserve important structures, therefore decreasing the risk of complications and improving the final outcome.

## **2. Preoperative planning**

The preoperative patient appointment is one of the most important steps in the breast revision process. Most patients seek evaluations from multiple surgeons, and it is crucial to make a great impression. The goal of the consult is to determine the patient's surgical goals, obtain medical information, perform a physical exam, develop a diagnosis, explain the recommended procedures with associated risks and benefits, and address the patient's expectations. It is the appointment where patients should be properly educated about the condition(s) and procedure options while establishing realistic expectations.

#### **2.1 Patient evaluation**

Preoperative evaluation of a patient is vital to any surgical procedure. First and foremost, it is imperative to review the patient's medical history and chief complaint. The chief complaint is the primary topic of discussion and must be in the patient's own words. The patient should be able to describe their concerns and may be guided with open-ended questions. A thorough evaluation should include medical diagnoses, medications with proper dosages and frequencies, allergies, and past surgical history. The patient's social history must be obtained, and the discussion must focus on the use of tobacco or nicotine-containing products due to concerns of compromised vasculature and wound healing. Finally, social history should include the patient's profession as the patient may have restrictions of their work-related duties. Lastly, the surgeon should determine if there is any family history of cancer, as well as any previous mammograms. Those patients over the age of 40 or patients who are of high risk should undergo a mammography prior to surgery [2].

#### **2.2 Patient examination**

The physical examination begins with a visual inspection of the breasts. The key areas to evaluate during the breast examination are the skin envelope (laxity and quality), breast volume, position of the nipple-areola complex, areolar size, degree of ptosis, asymmetries, and pocket location of the implants. Mallucci and Branford stated *Revisions for Complications of Aesthetic Breast Surgery DOI: http://dx.doi.org/10.5772/intechopen.112915*

the four pivotal elements in breast aesthetics are: proportion of the upper pole to lower pole, angulation of the nipple, upper pole slope, and lower pole convexity [3].

The surgeon must be able to identify any asymmetries, implant malposition, and size discrepancies. It is important to note that a size difference of <10% is considered within normal limits [4]. Aside from breast morphology, the surgeon must also identify any deformities of the chest or spine that may lead to an asymmetry. Lastly, the breasts and axilla should be palpated to evaluate for the presence of masses or lymphadenopathy, including the associated lymphatic chain of the supraclavicular and axillary lymph nodes.

A grading system to evaluate breast ptosis was developed by Dr. Paule Regnault. The grade of breast ptosis is determined by the position of the nipple in relation to the inframammary fold (IMF) and skin envelope (**Figure 1**, **Table 1**) [5].

The last part of the examination involves obtaining breast measurements and photos (**Figure 2**). These measurements include: [3, 4, 6–8].

1.Breast width (BW): Measurement of the most medial to the anterior axillary line

2.Breast thickness (BT): Measurement of the thickness of the upper pole

3. Sternal notch to nipple (SN-N): Ideal measurement of 19–21 cm

4.Mid-clavicle to areola (MC-A): ideal measurement of 19–21 cm

5. Inter-nipple distance: Ideal measurement of 19–21 cm

#### **Figure 1.**

*Breast ptosis classification [5]. A: normal, B: 1st degree, C: 2nd degree, D: 3rd degree, and E: glandular ptosis.*


#### **Table 1.**

*Regnault's classification of breast ptosis [5].*

**Figure 2.** *Breast measurements and 'ideal' base width.*


The most crucial measurements in breast revision surgery are the breast width, sternal notch to nipple, and nipple to inframammary fold. The 'ideal' or desired base width (BW) is typically different from the actual BW of the native breast tissue and can most often be measured as the distance from the anterior axillary line to within 1 cm from the chest midline. The goal or desired base width for the patient is used during implant sizing to achieve the ideal implant width (**Figure 2**). The breast width measurement assesses for the maximal implant width to avoid symmastia or lateral position of the breast implant. The nipple to inframammary fold measurement is critical to establish an esthetic lower pole fullness and overall breast shape. The sternal notch to nipple measurement determines the location of the nipple-areolar complex on the chest wall [6]. The surgeon must acknowledge these measurements and respect the limitations of the breast tissue.

The preoperative evaluation is imperative in order to allow for the surgeon to develop a sound surgical approach to achieve the best aesthetic outcome.

#### **2.3 Patient discussion**

The patient and the surgeon must be aware that no breasts are similar in shape and size and furthermore, breasts are rarely perfectly symmetrical. The surgeon must address the patient's desires while maintaining sound surgical parameters. The patient should be an active participant in the consultation by providing the chief complaint and expressing the desired outcomes. A well-educated patient understands the indications for various procedures and is aware of any limitations or possible complications. This assures a great provider patient experience with an aesthetic outcome.
