The reoperation cascade after breast augmentation

with implants: What the patient needs to know

Despite significant advances in the development of safer

cohesive gel breast implants, providing form-stable devices

in a wide range of shapes and sizes to accommodate the

aesthetic demands of women undergoing breast augmentation,

even the most experienced surgeons continue to

report high complication rates for the procedure. Whereas

other common elective surgeries such as total hip

replacement or even much less invasive aesthetic procedures

such as blepharoplasty are associated reoperation

rates of below 3%,the numbers for breast augmentation

reaching up to 30% within the first 6 years remain

unmatched.There seems to be a significant

discrepancy between the lightness with which breast

augmentation is elected and sold in the media and the

seriousness of the possible sequelae. Not only is each

reoperation associated with all the general risks of surgery,

but also involves other issues such as the financial burden,

convalescence and time off work

Analysis of patients having undergone

either implant replacement or implant removal

following breast augmentation , three

key issues were identified: (1) revision surgery following

breast augmentation is very common, (2) the risk of

requiring further revision procedures after the first one is

high and (3) the time interval between subsequent revision

operations becomes significantly shorter.

In accordance with the literature, by far the most common indication for revision surgery in the aestheticgroup in was capsular contracture.Contrary to this, the desire for larger implants and malposition were the main reasons for transsexuals and malformation patients.

The average time between primary augmentation and the first revision procedure was nearly 10years for aesthetic patients, which was significantly longer

No distinct correlation between the type of primary or secondary surgery, with regards to incision, implant type or treatment of capsule, and the incidence of multiple revision procedures could be identified. Also, the experience of the surgeon performing either the primary or secondary operation had no significant impact on the number of revisions.Most surgeons will agree that revision procedures of any kind are significantly more challenging than operating in a virgin surgical field. Scar tissue and distorted anatomy are major contributing factors to the incidence of complications.

Revision procedures in the case of breast augmentation frequently require a change of incision be that from periareolar to submammary or more invasively to a circumvertical mastopexy patterntherefore inflicting additional wound area, tissue destruction and scar formation on the patient.

Moreover, with the additional progressive atrophy of breast tissue in these often very slim patients, ensuring adequate soft tissue coverage of the implant becomes increasingly difficult, thus leading to both functionally and aesthetically inferior results.

Interestingly, the indications for implant exchange in patients from other institutions were predominately medical, such as infection, capsular contracture or device failure, whereas in our own patients aesthetic issues were more common. Patients are ‘lost’ or ‘gained’ for a multitude of reasons, ranging from trust or other patientedoctor relationship difficulties, to logistic or financial issues. One explanation for could be that patients with ‘medical indications’ for implant exchange who have been augmented in smaller private clinics are more likely to choose to undergo revisions at an institution perhaps providing more extensive medical care facilities.

The fact that in many European countries medical indications for implant exchange will be partially covered by health insurance, but only when performed at a public hospitalwith a certified plastic surgery department, couldcertainly be another relevant factor. How many of our own patients have gone on to seek corrective procedures elsewhere and at what kind of other institutions will remain unknown; however, we do assume that the mix of patients in our cohort is a representative reflection of the general trend in patient migration. In the patients requiring further reoperations after the first implant exchange, a distinct shift of indications could be noted. Thus, primarily aesthetic revision patients more frequently developed medical problems requiring further interventions and patients with medically indicated implant exchange more often presented with aesthetic complaints.Explanations for this finding must of course also be speculative.

One contributing factor could be that the most common medical reason for primary implant exchange was capsular contracture, which is almost always also associated with a significant aesthetic component. Having solved the ‘medical’ part of the problem with the implant exchange, the patient’s attention may then be drawn to aesthetic aspects, which were probably present to a certain degree before the primary implant exchange was performed.

Why the patients with primarily aesthetic issues go on to have medical complications is less clear. However, one must assume that there is again probably a certain degree of bias regarding the type of patient electing treatment at a public training hospital. The fact that patients with sometimes even minor aesthetic complaints requesting corrective procedures are at great risk for complications highlights the importance of patient selection. It is these cases in particular, wheremthe surgeon must be sensitive to when ‘better is the enemy of good’. Thus a patient who is adequately educated about the possibility that the aestheticresult may not entirely meet their expectations and conception of a perfect outcome will have a higher threshold for electing corrective procedures and exposing themselves to the substantial risk of both medical and aesthetic complications

we chose to focus on patients having undergone a significant revision procedure such as implant removal or exchange as an objective determinant of long term complications following breast augmentation. It is our opinion that the discussion about the terminology of complications, revision surgery or reoperation is academic and irrelevant. Whether the patient requires a reoperation due to a known long-term pathophysiological development such as capsular contracture or a more aesthetic reason such as size or malposition does not alter the impact of the procedure. At the end of the day most, especially young patients requesting breast augmentation are mentally signing up for one life-long lasting procedure Whilst promising alternative methods of breast enlargement with autologous tissues such as lipofilling or other tissue engineering-based techniques are still being established, augmentation with implants still remains standard.

It is our impression that these facts are insufficiently incorporated into the patient selection process by surgeons performing prosthetic breast augmentation and not conveyed enough to patients electing the procedure, especially since very young patients may require secondary surgery even before the age of 30.

Careful patient selection and comprehensive patient information alone can significantly reduce complication rates and generally lead to greater patient satisfaction. We therefore conclude that the high risk and potentially arduous consequences of revision surgery hould routinely be stated as such in the written consent for the procedure.