title: Approaching revisional surgery in augmentation and mastopexy/augmentation patients.
abstract: BACKGROUND
  Breast augmentation and mastopexy augmentation procedures are becoming more common. The young plastic and reconstructive surgeon is often challenged revisional surgery operations in these patients. These cases are challenging, require significant operative time, and can be associated with a high revision rate. It is important for the young surgeon to have an approach to deal with these common and difficult scenarios.
  
  
  METHODS
  A retrospective chart review was conducted on all patients who underwent a revision augmentation or revision mastopexy augmentation procedure between 2008 and 2010 by the authors. The most commonly encountered mitigating circumstances in the revision augmentation or revision mastopexy augmentation populations were identified and an algorithm was created on how to address these difficult problems.
  
  
  RESULTS
  Between July 1, 2008 and July 1, 2010, 264 patients underwent revision augmentation or revision mastopexy augmentation procedures. The most commonly encountered patient scenarios were recurrence of ptosis, recurrent capsular contracture, implant malposition, rippling, and desiring a reduction in implant size. We encountered many mitigating circumstances that complicated the revisions. We devised a stepwise algorithmic approach to address these problems based on the following factors: (1) blood supply to the nipple-areola complex, (2) need to change implant plane, (3) patient desire to reduce or increase in breast implant volume, (4) need for total en bloc capsulectomy or capsulorrhaphy, (5) incision approach used to perform the capsulectomy, and (6) patient-related factors that need to be medically optimized or treated before, during, and after surgery. By adhering to these steps, outcomes can be accomplished more reliably and safely.
  
  
  CONCLUSIONS
  Specialized preoperative planning is necessary to consistently deliver safe and aesthetic revision augmentation and revision mastopexy augmentation results. It is important for the operative surgeon to carefully consider the potential adverse effect of implants and prior mastopexy or reduction incisions and patterns on the blood supply to the nipple-areola complex. With educated planning, successful results can be achieved in most cases, and the risk of serious complications can be minimized.
authors.affiliation: Brian P. Dickinson, M.D., Inc., Newport Beach, CA, USA. drbriandickinson@drbriandickinson.com
authors.forename: Brian P
authors.initials: BP
authors.lastname: Dickinson
authors.forename: Neal
authors.initials: N
authors.lastname: Handel
mesh_terms: D000328:Adult; D000465:Algorithms; D018427:Breast Implants / Q000009:adverse effects; D003661:Decision Support Techniques; D005260:Female; D006801:Humans; D016462:Mammaplasty / Q000295:instrumentation / Q000379:methods*; D008875:Middle Aged; D009558:Nipples / Q000098:blood supply / Q000601:surgery; D017060:Patient Satisfaction; D011183:Postoperative Complications / Q000517:prevention & control; D012086:Reoperation; D012189:Retrospective Studies