**9. Revision mastopexy/augmentation**

 Revision mastopexy/augmentation surgery can be quite difficult but also very rewarding and is a necessary component for anyone offering these procedures. The acknowledgment of an undetermined blood supply and the potential for NAC ischemia is paramount when considering revision surgery. Although prior operative reports may be beneficial, they can be unreliable as to the actual pedicle utilized and great caution must be used. Avoidance of wide excision patterns or significant

#### *The Art of Body Contouring*

 undermining is advisable. Occasionally multiple pedicles can be combined in some situations to help limit ischemia when the prior pedicle use is unknown (**Figure 17**). Foremost, patients requiring a second mastopexy with or without implant replacement should be informed and educated about potential loss of skin and/or the NAC. Some revision cases may require staging, particularly if they have large subglandular implants, due to the inability to depend on accessory central blood supply to the nipple. The addition of capsular contracture and need for capsulectomy adds even more risk. These patients likely require explantation and capsulectomy first followed by revision mastopexy/augmentation secondarily. When choosing to perform a simultaneous revision mastopexy augmentation and pocket exchange the surgeon must be extra diligent to limit any maneuver that compromises vascularity more than absolutely required (**Figure 18**). The pectoral artery branches have

#### **Figure 17.**

*Patients who have had previous mastopexy & augmentation of an unknown pedicle type present potentially more risk. When possible, using limited dissection and a combined pedicle such as the superomedial-inferior (SMI) shown can avoid unwanted disruption of already decreased vascularity to the NAC.* 

#### **Figure 18.**

*The patient shown has the classic problem from a circumferential mastopexy that stretched vertically and residual ptosis. She was corrected by complete capsulectomies, new total submuscular implants and revision vertical mastopexy.* 

#### **Figure 19.**

*Revision on a patient who had a circumferential mastopexy and the more common widening pattern of scar formation. The patient wanted smaller areola with better scars, perkier breast and slightly smaller size breast than before.* 

#### **Figure 20.**

*The figure demonstrates revision on a patient with multiple past surgeries of various types and chronic history of capsular contracture. Damage to the residual muscle necessitates the use of an acellular dermal matrix to connect the residual lateral pectoralis border to the new IMF.* 

already been severed from the past Submammary augmentation removing the normal central pedicle portion of vascularity.

 Unsatisfactory scarring is typically the most required revision and fortunately is often fairly straightforward. The opposing forces of mastopexy skin excision and augmenting breast volume may lead to widened and unsatisfactory scars on occasion. This is usually remedied with standard scar revision techniques and has a high rate of success with a careful tension free closure. NAC irregularity or asymmetry can be seen and is typically improved best by adding a vertical incision to reduce tension around the NAC. Of particular note is the tendency for isolated periareolar lifts to widen with time, independent of suture type used and especially when combined with augmentation (**Figure 19**). The proper correction of this relies on the addition of a small vertical

#### **Figure 21.**

*Damage to the residual muscle shown was corrected by excising the old capsules from multiple surgeries and developing an inferolateral submuscular flap to elevate the serratus and external oblique as shown. Recruited muscle and fascia was used in place of an ADM.* 

#### **Figure 22.**

*Simultaneous correction of ptosis and symmastia was performed using an inverted T mastopexy because of the extent of excess skin and new pocket creation to correct the symmastia.* 

component with periareolar revision. This will take tension off the new areolar diameter and return a more conical appliance to the breast that is often flattened with Benelli-type lifts.

Implant malposition is a common complication with augmentation alone and is certainly encountered with post mastopexy/augmentation. The most common malposition is inferiorly and laterally. Standard pocket modification procedures are similarly beneficial as they are post augmentation alone. However, soft tissue reinforcement may be required as some patients will have less than desired intrinsic tissue integrity. Acellular dermis and bio-resorbable silk derived scaffolds are the mainstays of tissue reinforcement in reconstructive cases and have been used with success in the revision of cosmetic breast cases (**Figure 20**) [3]. This is particularly true when capsular contracture exists and multiple surgeries in the past have taken place. Occasional localized adjacent muscle flaps can be used to

cover the gaps and gain better implant coverage (**Figure 21**). Revision of symmastia if found simultaneously with ptosis issues requires either staging, new pocket development, or ADM usage (**Figure 22**).
