Corrective Breast Reconstruction: Understand Your Options

Breast Implant Revision: Solutions

Breast implants are not intended to last indefinitely. Eventually, breast implants will require replacement. While breast implants filled with saline or silicone gel can last for 25 years or longer, on average, they need to be replaced every ten to fifteen years or so. Therefore, even if you underwent reconstruction with breast implants years ago and are currently satisfied with your results, you should familiarize yourself with the available solutions for secondary reconstruction. It is important that you, as a patient, educate yourself about these solutions so that you can make the most informed and confident decisions regarding your body when the time arrives.

Many mastectomy patients in need of breast implant revision believe that their best available option, if not their only option, is to have their breast implants replaced. This is not necessarily the case. If you are experiencing problems with your breast implants, Dr. Lerman can evaluate your case and explain which options are best suited to restoring your breasts. Depending on the problems you are experiencing, you may be a good candidate for one or more of the following solutions:

1. Breast Lift

Problem: Both natural breasts have been replaced with breast implants. Over time the weight of the implant can cause the breast implant to shift and become displaced. Additionally the thin skin left over after mastectomy weakens and ptosis, or sagging, occurs due to lack of adequate internal support for the implants.

• Solution: Dr. Lerman can reinforce the implant using AlloDerm® or other Biologic Mesh to create an internal sling or internal bra which provides additional support for the implants and corrects malpositioning. Any excess skin that results in an aesthetically displeasing appearance can be carefully excised. The lifted breasts will appear more natural and youthful, while the reinforced breast pockets will help to prevent future sagging.

Problem: Only one breast was reconstructed using an implant. The natural breast continued to change over time, resulting in asymmetry between the two breasts.

• Solution: Dr. Lerman can perform conventional breast lift surgery on the natural breast, removing excess breast tissue and skin to restore symmetry between the breasts. While exact symmetry between a reconstructed breast and a natural breast may be impossible to achieve, patients can expect significant aesthetic improvements.

2. Minor Revision to Breast Skin Envelope

Problem: Visible rippling of the implant becomes evident as the breast skin envelope stretches and becomes thinner over the years.

• Solution: AlloDerm® can be used to camouflage rippling by providing a layer of tissue between the implant and the thinning skin envelope. If necessary, the skin envelope can also be tightened to create a snugger pocket for the implant.
• Solution: Fat Grafting can be used to camouflage rippling or other contour abnormalities by providing a layer of tissue between the implant and the thinning skin envelope. If necessary, the skin envelope can also be tightened to create a snugger pocket for the implant.

3. Perform DIEP Flap Breast Reconstruction

Problem: The patient wishes to replace her breast implants due to rupture, rippling, capsular contracture (formation of scar tissue around the implant that causes the breast to harden), or other deformities that have developed over time. Alternatively, she may want to replace her breast implants simply because she is dissatisfied with their appearance in general and wants to achieve a more natural, aesthetically appealing result.

• Solution: Rather than simply replacing the implants or revising the implants, which may never achieve the optimal result, Dr. Lerman can remove the breast implants all together and perform autologous breast reconstruction using one of a variety of natural tissue flap choices from the patients own body. The most common is the DIEP (deep inferior epigastric perforator) flap breast reconstruction from the excess skin and fat of the lower belly. 

The DIEP procedure is the most advanced method of breast reconstruction currently available. While it is generally the preferred technique for restoring the breasts after mastectomy, it can also be performed as a corrective procedure. Dr. Lerman uses autologous tissues - tissues from the patient's own body - to create a new, entirely natural breast.

The DIEP flap procedure is named after the deep inferior epigastric artery perforator, which is located in the abdomen. The procedure is considered minimally invasive in that only fat, skin, and blood vessels are removed from the abdominal region and relocated to the chest to create a breast. Unlike the TRAM flap, no muscle tissues are removed during the DIEP flap procedure.

The actual DIEP flap comprises tissues removed from just below the navel, as the fatty tissue in this region is remarkably similar to that of natural breasts. Using microsurgical techniques, Dr. Lerman transplants the DIEP flap to the chest, reattaching the blood vessels with meticulous care. He then shapes the DIEP flap to resemble a natural breast.

Depending on the needs of the patient, it may be possible to reconstruct the breast using a single DIEP flap, or it may be necessary to transplant a second DIEP flap. These flaps can be connected together using microsurgical techniques to form a single breast through a procedure called stacked DIEP flap.

Some patients have a flat belly without adequate fatty tissue to perform a DIEP flap but still want autologous (natural) reconstruction. Dr. Lerman performs all types of perforator flap reconstructions including PAP flap (posterior upper thigh), sGAP & iGAP flaps (buttocks) as well as others

The risk of abdominal weakness or bulge is minimized with a DIEP flap reconstruction as opposed to the old fasion TRAM flap surgery. Post-operational scar patterns between the two procedures are similar.

The benefits of corrective breast reconstruction using the DIEP flap technique include:

• Breasts that not only look more natural but also feel more natural than those reconstructed using implants. These natural tissue breasts will move like natural tissue with normal movement such as sleeping on your side or stomach in bed and wearing push up bras and bathing suits.
• There is no further need to worry about the problems associated with breast implants, such as rupture and capsular contracture. The DIEP flap (and other perforator flap tissue reconstructions) last you for the rest of your life. The tissue will age over time and often feels softer and looks more natural as time goes by as opposed to breast implants which never look better over time.
• Patients emerge from the procedure with flatter, tighter, trimmer abdominal contour, as a variation on the "tummy tuck" procedure is performed to obtain the DIEP flap.
• Compared to the TRAM flap technique, which uses a small amount of muscle even in its "muscle-sparing" version, the DIEP flap does not unduly weaken the abdominal wall.
• In some patients recovery of some of the sensation of their breast is possible by performing sensory nerve reconstruction.

4. Place New Breast Implants

Problem: As above, the patient wishes to replace her breast implants due to rupture, capsular contracture (formation of scar tissue around the implant that causes the breast to harden), or other deformities that have developed over time.

• Solution: Dr. Lerman replaces the old breast implants with new implants.

If a patient is inclined to replace her existing implants with new implants, Dr. Lerman strongly encourages her to consider the new FormStable Highly Cohesive Anatomically Shaped Silicone-Gel Filled Breast Implants, colloquially known as "gummy bear" implants.

Approved by the American Food and Drug Administration (FDA) in 2013 after years of use in other countries, cohesive-gel implants are particularly well suited to women who have undergone mastectomy. Because the consistency of these implants is highly cohesive and they are 'form stable' they are far more likely to maintain their shape over time. Visible abnormalities such as rippling and folding are not as likely to occur as they are with other breast implants.

It is important to note, however, that form stable 'gummy bear' implants, like all breast implants, are not intended to last forever and will likely require replacement over time. For the right candidates, these newer implants offer benefits to breast reconstruction patients that their counterparts cannot match.

Flap Revision

In general, problems with breasts reconstructed using autologous tissues occur less commonly than those arising from breasts reconstructed using implants. When they do occur, they can usually be solved through minimally invasive surgical techniques.

Possible problems that can occur with transplanted flaps include:

• The need to correct flaps that are too full: If a flap is too large, causing the breasts to appear asymmetrical, Dr. Lerman can reduce the fullness of the reconstructed breast by performing liposuction, skin excision, or a combination of the two.
• Indentation, contour abnormality, or asymmetry of the breast mound: If there is dimpling, denting, concavity or unsatisfactory shape in the soft tissues of the reconstructed breast, Dr. Lerman may be able to improve its appearance by harvesting fat from other parts of the body via liposuction and strategically injecting (Fat Grafting) it into the problem areas.
• Fat necrosis: This refers to a condition that occurs when the fat in the transplanted flap does not receive an adequate amount of blood. It is more common in pedicled TRAM flaps than in the more advanced DIEP flap. As a result, scar tissue forms; this scar tissue can feel firm. While cancer recurrence will have to be ruled out, fat necrosis can be surgically removed.

Lumpectomy Revision

Lumpectomy is a popular treatment for breast cancer. The benefit is that the majority of the breast mound is preserved. It is however often combined with radiation and although breast surgeons attempt to preserve the cosmetic appearance of the breast it often leaves a contour abnormality, asymmetry or in worst case disfigured breast. Because each lumpectomy is unique in terms of the tissues removed, the subsequent reconstruction must address the unique aspects of this disfigurement.

Often, other complicating factors such as ptosis (sagging) of the affected or opposite breast, size discrepancy between the breasts, indentation of the affected breast, or another abnormality that develops.

If only minor revision of the reconstructed breast is necessary - for example, due to denting of the soft tissues - it may be possible to achieve excellent results through fat grafting. If more substantial improvement of the breast contour is necessary, then DIEP flap reconstruction may be performed.

Of course, if the reconstructed breast and the natural breast are not symmetrical, then conventional breast lift or breast reduction can be performed on the natural breast to restore symmetry.

Does Medical Insurance Cover Corrective Breast Reconstruction?

Yes. According to the 1998 Federal Women's Health and Cancer Rights Act, medical insurance policies must cover every phase of a woman's breast reconstruction. This includes corrective or revision breast reconstruction even if it is years later.

Learn More about Corrective Breast Reconstruction

If you would like to learn more about your corrective breast reconstruction options, or you wish to schedule your initial consultation with plastic surgeon Oren Z. Lerman, please contact our plastic surgery practice in Manhattan today. We would be pleased to answer any questions you may have about breast reconstruction revision and assist you however we can.