Revisional surgery following breast reduction

Nipple-areola complex (NAC)

Circulatory disorders affecting the nipple and areola are rare but may cause a significant deformity in this area of the breast.

Blistering and crusting of the areola occurs if the lack of blood supply is temporarily reduced. The wound usually heals spontaneously but tends to leave an area of scar tissue which contains less pigment.

Once the scar has fully matured and if the basic structure of the nipple and areola has been preserved, this area can be tattooed, to restore the natural appearance of the areola.

If the blood supply is severely impaired, the nipple and areola may necrose. In this instance, the cosmetic deformity is much worse. The necrotic skin has to be excised and the healthy wound closed with stitches.

Once the scar has matured, nipple reconstruction can be performed

Breast tissue

This complication is extremely rare but has serious consequences.

Patients with a pre-existing vascular disorder and those in whom the wrong surgical technique is employed are at significant risk. A portion of their breast tissue may die and become infected following surgery. This can lead to abscess formation or a cutaneous fistula.

If large areas of the breast are involved, a significant loss of volume and extensive scarring may result.

In smaller areas, fat necrosis can occur. An area of breast tissue is transformed into a hardened mass, consisting of oil mixed with small cysts.

On palpation, an area of fat necrosis feels similar to a malignant lesion, although fat necrosis is an entirely benign process. However, it may cause confusion during mammography.

The treatment of fat necrosis varies. Small areas can be monitored but large areas may have to be surgically excised, if the wounds break down or tissue becomes infected.

Ideally, it is useful to wait, possibly for several months, to determine which areas of the breast tissue will recover.
If large areas are excised, it may be necessary to consider autologous breast reconstruction.

Scarring

Scars positioned on the lower part of the breast usually heal very well. The length of the scar tends to be proportional to the amount of breast tissue removed; the larger the breast reduction, the longer the scars.

Hypertrophic scarring occurs when excess scar tissue forms. The scar typically becomes red, raised, firmer and wider. This can be distressing for patients but is often genetically determined.

Hypertrophic scars are initially treated by regular massage and the application of pressure. This can be combined with a series of intralesional cortisone injections. In severe cases of hypertrophic scarring, surgical excision followed by local irradiation may be necessary.

Excess skin can sometimes gather at the lower aspect of the vertical scar or at both ends of the horizontal scar. This is known as a ‘dog ear’. These can be surgically excised if they are very prominent or if a patient finds them uncomfortable or unsightly.

Finally, all scars may stretch and become wider, warranting surgical revision to improve their appearance.

Assymetry

As with all breast operations, a small amount of residual asymmetry is inevitable, as no two breasts are entirely identical.

Any asymmetry may be related to the breast volume or shape. If there is a volume difference, this can be corrected by reducing the larger breast or by augmenting the smaller breast. The breast shape can be improved by resecting limited amounts of skin or by moving the position of the nipple/ areolar complex.

If the nipple/ areola complex ends up being positioned too high or too low on the breast mound, it reflects poor pre-operative planning. An areola that is too low can easily be corrected, using the same scars that were used for the breast reduction. However, an areola that has been placed too high is a much more difficult problem to correct. Lowering the areolar can leave significant scars that are visible when wearing a bikini or low cut top.

Nipple retraction 

Nipple retraction may also occur following breast reduction surgery. The scar tissue that forms underneath the nipple/ areola complex can cause the nipple to be pulled inwards. This usually occurs due to the influence of gravity on the healed glandular tissue. Nipple retraction is however, surgically correctable.

Volume shape

Massive weight loss patients tend to lose a significant amount of glandular tissue, however, the surrounding skin does not change. As a result, the breasts tend to sag and lose projection.

A patient may opt to have the breast volume increased and this can be achieved using standard augmentation techniques. Alternatively, a breast lift may be performed to improve the breast shape.

Conversely, patients with significant weight gain tend to increase their breast volume. These patients may opt for a secondary breast reduction, which can be performed through their previous scars.

It is important that patients who are prone to weight fluctuations achieve a stable weight, which should be maintained for at least one year, before undergoing further breast reduction surgery.

As a result of the natural ageing process, the breast envelope can lose elasticity and firmness. It is especially common in the lower part of the breast, which is the area most effected by gravity. This results in an unattractive shape, where the areola remains in place, but the glandular breast tissue descends towards the lower pole of the breast. This deformity is particularly common after a vertical scar breast reduction.

It occurs because insufficient skin was removed from the lower pole of the breast at the first operation. In order to correct this, the glandular breast tissue needs to be reshaped and positioned higher. This can be done through the existing scars but often, it is also often necessary to excise skin at the lower poles, both horizontally and vertically.

Fig. 1a	Fig. 1b

Figure 1: Pre-operative picture (a) of a breast reduction patient, in whom the nipple-areolar complexes were positioned too high on the breasts. Post-operative picture (b) demonstrating corrected nipple heights. The scars above the areolas are inevitable.