He performs the full gamut of face-body aesthetic surgeries at his San Diego practice, but for plastic surgeon Joseph L. Grzeskiewicz, MD, the art of breast-revision surgery is especially rewarding and something he describes as “having a special and important place” in our collective repertoire. “The most common revision surgery I perform in my practice is revision of breast surgery. This encompasses all kinds of prior breast surgery including augmentations, lifts, reductions and reconstructions,” he explains. “Male, female, transgender and other gender-fluid persons all share a keen interest in breast surgery, so it is widely popular, and its effects, both good and bad, are very significant. Breast surgery holds a very emotional and cultural significance in our society. The aesthetics of the breast—female and male—are, for whatever reason, very important to us, and when elective surgery undertaken to improve those qualities goes wrong, it can be devastating.” Here, Dr. Grzeskiewicz details what goes into the surgery, as well as common misconceptions about the procedure.
What are some common misconceptions about revision surgery?
Revision surgery is easy or simple.
“I think that, sometimes, people believe that a revision should be easier than the primary (or any prior surgery in the case of multiple prior procedures) because it is just ‘fixing’ a specific problem or it is somehow a lesser version of the original surgery. It seems as though it should be just a ‘minor tweak,’ or there is always a standard approach to all problems that can arise—but this is not accurate at all. Many times, the best solution for a specific problem with a specific patient is a unique approach or a novel way to apply something that has worked in a similar case in the past.”
Revision surgery is the same as the primary surgery from the standpoint of risk, effort required or concept and technique.
“Usually, the truth is just the opposite. Revision surgery is often riskier than primary surgery, it is typically more difficult or challenging from both a planning and an execution standpoint, and it often requires a totally different approach than what the previous surgeon(s) offered. If ‘Plan A’ didn’t work the first time, then we usually can’t expect ‘Plan A’ to work the next time.”
The outcome of a revision procedure can be guaranteed—or at least it is equally or more certain to succeed than the primary, or previous, surgery.
“Unfortunately, this is not the case, although revision surgeons and patients both might desperately want it to be so. The problems leading to revision surgery are frequently very difficult, and the revision surgeon is often starting from ‘behind the eight ball.’ Thus, while a plan may be solid and rational, there are often more risks and more factors going against the revision surgeon than the primary surgeon.”
Surgeons who perform primary surgery well can perform revision surgery with the same expertise.
“While many surgeons who perform primary surgery well are equally adept at revision surgery, unfortunately, this is not generally the case. Revision surgery requires a totally different thought process and skill set. When I was a young surgeon, I used to dread complex revision cases because they are hard, and the outcome is uncertain. As I have gained experience with different problems and solutions, my skills have sharpened, and my understanding of the surgery has grown, and I now welcome it. While it is still every bit as challenging, the challenges feel different to me now, and I am certainly more equipped to meet those challenges. Thus, it is more rewarding and satisfying. There is some confusion, or at least debate, surrounding the best word to use to define this type of surgery—revisional or revisionary. Both apply, but in my opinion, at least in the case of most of the breast procedures I perform, it truly is more revisionary; it truly requires a whole new vision and approach to the current problem. A surgeon performing a lot of revision breast surgery has to have a wide range of experience with all kinds of problems in breast surgery and different ways of solving them, and he or she has to be an out-of-the- box thinker.”
If you need or want a revision, it’s because you got “botched.”
“The word ‘botched’ as it relates to surgery of all kinds has been in our vocabulary for some time now. With the popularity of aesthetic surgery and the portrayal of plastic surgery in the media, that word has become even more deeply ingrained in the vernacular. In general, I think that the term is inflammatory, and I really don’t like to use it myself to describe procedures or outcomes that are not satisfactory, but I will if it allows me to reach people better and help them understand the reality of their situation. To me, the word ‘botched’ implies a certain lack of skill or attention by previous surgeons, or even a willful neglect or intentional effort to achieve a poor outcome; in short, malpractice. While there is no question that, unfortunately, sometimes those things happen, it is my opinion that many, if not most, of the poor outcomes that we see for revisions are not the result of such ‘botched’ procedures, rather just things that didn’t work out the way the surgeon planned it, or a surgeon’s earnest attempt to obtain an excellent result fell short of that mark for some reason.”
What makes a revision surgery more difficult (or different) than a “regular” surgery?
Someone has already “been there.”
“The anatomy and tissues are changed, blood supply is altered, scar tissue is present, and our options are more limited. We are often constrained by the absence or permanent alteration of structures or tissues that have been removed, tightened, repositioned, or changed in some other way. When incisions are made in tissues their blood supply is altered, and this often affects our ability to safely do certain things with those tissues.”
The risks are greater.
“Because tissues are altered and often compromised in some way by previous surgery, the revision surgeon must be especially careful to assess not only the standard risks that come with any such surgery, but the specific or unique risks imposed by the previously operated state. Sometimes there is a higher risk of loss of part of the breast, like the nipple or other important skin, or a higher risk of asymmetry or contour irregularities, infections, and scarring or wound healing problems.”
Emotions are high.
Patients seeking revision surgery often feel ‘stupid,’ guilty, or frustrated. They may feel as though they made a bad decision or were ‘fooled’ by a previous surgeon, that they didn’t research the surgery well enough, or that they deserve a bad outcome because of making a vain or narcissistic decision to have elective aesthetic surgery. They sometimes feel guilty for creating a hardship for themselves, their families, their coworkers, or even their previous surgeon. They can be angry at themselves or their previous surgeon because of a poor outcome. They often lack trust and don’t really want more surgery, yet they feel compelled because they are ‘stuck with’ a poor outcome or complication; they feel trapped. In addition to the frustration that revision patients often experience, especially those who have undergone more than one or multiple failed procedures in an attempt to correct a poor outcome, spouses or other family members are frustrated and don’t understand why these things are happening. Lastly, budgets are often strained as these patients pursue a satisfactory outcome with each attempt costing additional money. This itself creates a whole gamut of emotions from fear, anger, sadness, guilt, remorse, and frustration. The revision surgeon absolutely must be prepared to deal with all of these things in addition to coming up with a rational plan to solve the problem and performing impeccably to execute that plan.”
Revision surgery is an “autopsy of a failed procedure.”
As a revision surgeon, I have believed this about revision surgery for a while now, and not as a judgment against those surgeons who have come before me, but as an objective assessment of what I am doing when I perform a revisionary procedure. Like any surgeon who operates enough and is honest with you, I must tell you that I sometimes have to revise procedures of my own. That is just the nature of surgery. Simply put, the procedures that were done before a revision did not work to accomplish the goal. Otherwise, we would not be attempting to revise it. Thus, it failed in that aspect, even if everything seemed right preoperatively. When I do a revision, I get an opportunity to examine up close the reasons why the previous procedure failed, and if I can identify something that can be changed for next time, I have learned something of great value. That makes me a better surgeon for the future, and I think this is one of the most important keys to success as a surgeon: it’s not whether we have complications or ever need to revise our work; it’s whether we are introspective and learn how we can minimize the chances of that, and that is what gives some surgeons an edge with respect to needing to do fewer revisions or having fewer poor outcomes in their own work. Thoughtfully evaluating and revising not only my own work over the years, but that of other surgeons, offers me the opportunity to do this at a large scale.”
What kind of emotional reaction comes from patients and a successful revision surgery that may not be present with other surgeries?
Naturally, the most enticing reason for performing revision surgery is the emotional response we get from the patients upon achieving a successful outcome. The emotions we see in successfully revising any aesthetic procedure usually have a different color or intensity than those we see in other types of surgery, and for the reasons we have been discussing about the significance of the breast, revisionary breast surgery can evoke those same emotional reactions. The typical emotions that we see are relief at finally solving a very challenging problem, pure joy at achieving a very difficult and often long sought-after goal, gratitude in the efforts of the surgeon who succeeds in solving their compelling problem, and solace in finally seeing their physical appearance come more into harmony with their psychological body image. They feel that a burden has been lifted, and their lives can now move on in a totally different way.”
Can you recall the most difficult or most rewarding revision surgery you’ve performed?
While there have been so many gratifying cases I have had the opportunity to be involved with over the years, one particularly rewarding revisionary breast surgery that I have performed involved a young lady who had undergone an elective breast lift and augmentation procedure to improve the appearance of her breasts. She had never been married, and she felt that the appearance of her breasts was very significant to her overall body image. She experienced wound-healing issues soon after her surgery, and despite the fact that she could see her implant breaking through her skin, there was a delay in her surgeon’s response, and she ultimately developed an infection necessitating removal of not only her implant on that side, but also a significant amount of infected and dying breast tissue.
This ultimately left her without an implant on that side and a severe deficiency of the lower part of that breast. Additionally, the lift procedure was not well done on the other breast, so that breast was not aesthetically pleasing either. This was a devastating blow to her, and she became very depressed and withdrawn. She stopped dating and immersed herself in work at her family’s business. She felt guilty and foolish for the decisions she made. When I met her, it was clear that an attempt at a straightforward replacement of an implant on that side, even with revision of the lift on both sides would fall short in producing a satisfactory result. She needed an individualized and unique approach. We performed two staged autologous fat transfer procedures in the office under local anesthesia about three-to-four months apart just to build back some of the volume and contour of the lower breast and to soften the hard scar and tight tissue left by her previous surgery.
Then, after months of that, we finally felt ready to attempt replacement of her implants. We placed a new, slightly larger implant on both sides, and revised the lift procedures on both breasts, and while we still have a few little adjustments left to make, she now feels ‘normal’ with her breasts, she can wear normal bras and other clothing, and she has normal movement and function of her arm and her body wall tissues. Through a very individualized plan that involved a staged approach over many months, multiple techniques like autologous fat transfer and liposuction contouring around the breasts and body wall as well as surgical replacement of breast implants and revisions of capsules and breast lifts, we have helped this young lady regain her life and her confidence to resume dating and socializing. Despite the few little adjustments left to make, she is very happy with her current progress, and the urgency to make those few small remaining changes is gone. This case perfectly exemplifies the rare combination of intellectual and technical challenge, emotional support during a very traumatic ordeal, and life-changing experience of success for both she and I that this kind of surgery entails.”
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