Revisions

	Because surgery is not an exact science (I often tell patients this is not "machine shop"), there are occasions where secondary surgery or revision may be necessary or at least beneficial toward achieving an optimal result. The most common postoperative residual deformity is the "dog ear", a tag of skin at the medial or lateral portion of the inframammary incision following the bilateral mastectomy with nipple areolar reconstruction ("double incision"). These can result when the breast are significantly drooped prior to surgery or when the patient has excessively large breasts or is markedly obese. More recently, I have become more aggressive in treating these conditions at the initial surgery. This does entail extending the incision, and thus the scar, further under the axilla (armpit) and sometimes angling it upward in this area. I believe the tradeoff of a slightly longer scar to avoid a secondary surgery is appropriate. Adverse scarring, in the form of spread or thickened scars can occur because of tension on the incisional closure or due to genetic factors in healing. Treatment of these may include certain topical applications such as Mederma, Scar Fade, Kelocote, or other preparations. Silicone sheeting or tape has been found to be effective in some cases. Finally, scar revision may be beneficial. This involves excising the problem scar or portion thereof and resuturing the incision with a careful layered closure. It should be understood that this does not guarantee that the adverse scarring will not recur. The surgeon will inform the patient if he or she feels the surgical revision is unlikely to gain much improvement. In markedly obese patients, those with high BMIs (body mass index), it may be expected that secondary surgery will be necessary to achieve a reasonable result. This is so because excessive fatty tissue extending under the arms and towards the back cannot easily be removed at the initial surgery. Liposuction may help some, but there will still be an excess of skin and subcutaneous tissue that will need to be removed at a later time to properly contour the upper torso. Weight loss prior to surgery can definitely benefit the patient and improve the outcome. Weight loss after surgery may improve the contour under the arm and around to the back to some extent. It is my policy to not charge the patient to perform a revision in most cases. However, the surgical facility and the anesthesia departments will charge a fee, though reduced from the original surgical fees. In those situations where a secondary surgery or revision is a predictable event, I do charge a fee. This fee is determined by the extent of the secondary surgery required and is determined when that surgery is scheduled.