Revision Reconstruction: What You Need to Know
Listen to the podcast to hear Dr. D discuss:
why a woman might consider revision reconstruction
the results of revision reconstruction: what to expect, as well as recovery and side effects
questions to ask a plastic surgeon if you’re considering revision reconstruction
Affiliations: St. Charles Surgical Hospital, Center for Restorative Breast Surgery
Areas of specialization: plastic surgery, breast reconstruction, plastic
and reconstructive microsurgery
Dr. Frank DellaCroce, or "Dr. D" as he has come to be known, is a founding partner of the Center for Restorative Breast Surgery and St. Charles Surgical Hospital in New Orleans. Board-certified in plastic surgery, Dr. D has performed thousands of reconstructive procedures,
both for women diagnosed with breast cancer and women at high risk of the disease who choose to have prophylactic breast removal. He is a Fellow of the American College of Surgeons and a member of numerous professional societies, including the American Society of Plastic and Reconstructive Surgery, the American Society for Reconstructive Microsurgery, and the World Society for Reconstructive Microsurgery. He also has been named one of the “Best Doctors in America.”
— Last updated on June 29, 2022, 2:45 PM
This podcast is made possible with the generous support of the Center for Restorative Breast Surgery.
Jamie DePolo: Hello, everyone. Welcome to this edition of the Breastcancer.org podcast. I’m Jamie DePolo, the senior editor at Breastcancer.org. Our guest today is Dr. Frank DellaCroce, or Dr. D as he has come to be known. He’s a founding partner of the Center for Restorative Breast Surgery and St. Charles Surgical Hospital in New Orleans.
Board-certified in plastic surgery, Dr. D has performed thousands of reconstructive procedures both for women diagnosed with breast cancer and women at high risk of the disease who choose to have prophylactic breast removal. He is a fellow of the American College of Surgeons and a member of numerous professional societies including the American Society of Plastic and Reconstructive Surgery, the American Society for Reconstructive Microsurgery, and the World Society for Reconstructive Microsurgery. He also has been named one of the best doctors in America.
Today he joins us to talk about revision reconstruction. Dr. D, welcome to the podcast.
Dr. D: Hi, Jamie. Thank you for having me. It’s a pleasure to be here.
Jamie DePolo: Yeah, thank you as always. It’s great to have you back.
So, we’re going to talk about a specific type of reconstruction, a revision reconstruction. And for somebody who may not be familiar with that, could you explain a little bit about what that is, and can it be done after both mastectomy and lumpectomy or is it a very specific thing?
Dr. D: Revision reconstruction can be thought of in a bunch of different ways. I guess the first obligation we have to our listeners is to kind of give them a sense of what we mean by that. We use interchangeable terms. Sometimes we call it corrective reconstruction, sometimes we call it a fix of a botched outcome, sometimes we call it revision. But what we’re basically talking about is repairing something that didn’t produce the intended result, fixing something that’s broken, redoing something that for whatever reason didn’t turn out the way it was hoped for, or there was some complication along the way that harmed the ultimate outcome and left deficiencies.
With respect to when can you repair or correct something that didn’t produce a breast reconstruction that is optimal, it can be done after just about any scenario that leaves room for improvement. Those include lumpectomies that have left a breast small or distorted or otherwise scarred in comparison with the other side, particularly when radiation is a component of that mix; it can be undertaken when an attempt at reconstruction following mastectomy either didn’t produce a breast with proper shape or the reconstructive attempt failed for whatever reason, be it an implant or a flat type operation; or if there was some complication along the way that left some residual disfigurement or some shortcoming.
Jamie DePolo: And that kind of leads into my next question. You gave some of the reasons why a woman might consider revision reconstruction. Are there others? I know I’ve talked to some women who have, say, ongoing pain from a reconstruction. And is that someone [who] might choose to think about revision reconstruction, if that’s happening?
Dr. D: Sure. You know, when we talk about the core problems that are left after a reconstructive effort doesn’t meet the measure of the mark, those can include shape or scarification deformities, and they can include chronic pain issues. It’s not infrequent that reconstruction, particularly with an implant or an expander, leaves some residual pain as a result of capsular contracture or some internal scarring or radiotherapy that contracted the envelope.
By the same token, if someone has never had reconstruction and they have tactile pain along the ribs or along the side of the chest wall, adding soft tissue and padding and protection can alleviate a lot of that.
And so there are multifaceted reasons someone might choose to undertake an effort at a remediation, at a redo, at a fixer upper, and those can include all of those things that leave some negative impact on quality of life.
Jamie DePolo: So essentially, if a woman is not happy with her reconstruction, then it sounds like revision is almost always an option.
Dr. D: Right. So that’s the good news and the encouragement in a scenario that seems to have, perhaps, an exhausted set of options for improvement. If the woman’s not happy, if the woman’s dissatisfied for whatever reason, the patient, the client, and they’re left with chronic pain or they’re left with even modest issues, there are often — with new technologies and new approaches and new attention to aesthetic detail — are often ways to make things better.
And so that’s the overriding encouraging message, is that even though there may not be some obvious things relative to your present care environment or things you’ve heard or things you’ve read about, technology’s always on the move. And we’ve come up with a lot of ways to repair the broken and to correct what I guess sometimes would seem the uncorrectable, and so those are good and optimistic thoughts to share with the audience.
Jamie DePolo: From your viewpoint as a surgeon, would you use different techniques for revision reconstruction than you would for an initial reconstruction, or is it the same type of options available?
Dr. D: So with respect to are the approaches different with a redo or a corrective or a revision reconstruction, the short answer is yes and no. And as I was alluding to, the question becomes “what has been attempted so far?” What resources have we used so far? Did someone have an effort at an abdominal flap that failed, and so that’s no longer an option? Did someone have an implant operation and they got an infection and lost some of their breast skin, so now we have to use a flap combination to rebuild that?
So revision and redo or corrective breast reconstruction is a whole level up in terms of necessary expertise and combining of what I like to think about are multimodality reconstructive techniques to rebuild a person who may or not still have the first-choice options available anymore. And so that’s where, you know… it’s sort of an over-utilized term, but thinking out of the box becomes an absolute necessity sometimes for someone who’s had multiple efforts and is left with a problematic situation and we have to combine the best of multiple things and the experience of 10 or 20 years to come up with unique solutions to their problem at that point.
Jamie DePolo: What about the recovery and the side effects? Are those pretty similar to original reconstructive surgery? I’m assuming if you use similar techniques that they probably would be, but I figured I should check.
Dr. D: I would say that the recovery and side effects, again, are all reflective of what combination of procedures we’ve used. If it’s simply a matter of going in and alleviating some scar tissue and a painful implant reconstruction, applying some dermal matrix or other things — very simple approaches — the recovery is fairly minimal. If we need to combine multiple flaps, then you have a few weeks of recovery to anticipate. But compared to the initial operation, not wildly different, really, in terms of practicality — basically the same.
Jamie DePolo: The question that is most important to everybody is the results. I know you talked about correcting the uncorrectable and fixing the unfixable. In your experience, are most women happy when they have revision reconstruction? Can their issues be resolved?
Dr. D: That’s a superb question, and the answer is this. For someone who’s been down a really hard road and had failed efforts at breast reconstruction, they’ve experienced loss multiple times. They experienced the loss of their breast with mastectomy, and then they experienced the loss of the hoped reconstruction. And then, if they had multiple efforts at that, they’ve gone through it over and over again in some cases. And so when we can deliver a quality outcome to that person, they’re beyond delighted. Their entire aura changes. It’s a phenomenal thing to watch, and it’s a fair bit of pressure on my side to try to deliver that, but it’s the level of satisfaction is really beyond adjectives for me to deliver on an interview like this. It’s transformative.
Jamie DePolo: That’s wonderful, and really good to hear. Now, also from your viewpoint as a plastic surgeon, do you need any sort of extra or special training to do a revision reconstruction as opposed to original reconstruction? Is that something that a surgeon would specialize in or is it that as you hone your craft and become very good at what you do, then people start referring the revisions to you? How does that work?
Dr. D: The answer is B. So revision/redo/corrective reconstruction, there really is no special training for that. That is a matter in terms of delivery of something, in those cases — a matter of experience. The easiest way to think about it is if someone has gone through failed efforts at breast reconstruction and the initial easiest or first-best options have fallen by the wayside, now we need to be able to combine innovative techniques, and we need to have a practitioner who is well experienced in all forms of breast reconstruction on a daily and weekly basis. Very experienced with implant reconstructions and what their limitations are, very experienced with every type of flap operation, very experienced with fat injection, very experienced with every modality. We talk a lot about not trying to fit a patient into a procedure… for someone who’s coming back for correction of the failed effort, now we need to reach and find the best components of what we have left available to us. And sometimes it takes combinations of many of those things to deliver what we need to deliver. And so training and so forth sets the foundation for being able to do that sort of work, but experience delivers the practical ability to approach a very complex problem and then break it down into its associated parts and see potential where the initial gestalt, the initial impression would be, “Oh, this is… We can’t do anything for you.” To be able to see past that and figure out what kinds of things can deliver some quality and beauty is a matter of just voluminous experience and complete dedication to the art, I think.
Jamie DePolo: So if someone is looking for a surgeon to do a revision surgery, it sounds like the best thing to do is look for someone with a lot of experience?
Dr. D: In some ways that becomes intuitive, because the woman who goes through a failed effort and —sometimes, you know, it’s not controlled, it’s not that he’s a bad doctor or you got bad luck. I mean, the human body is full of all kinds of quirks and black boxes and asymmetries and things that sometimes can create the unexpected. However, a lot of those variables can be mitigated or controlled by having someone take the reins who’s been down that trail a thousand times.
You know, you try to play the odds in your favor because the reality is this: If we had a failed effort or two or three or however many times, and now we’re going to give one good go at it for this last attempt to give something back that’s going to be remarkable, we really don’t want to take any chances with this one. We really, you know… we’re all in, and so let’s give ourselves the best opportunity. And I think people and women, humans in general, get that on a basic level.
When it gets to that point, do your homework and then do it again and do it again, and make sure that you’re discriminating, and don’t be afraid to ask hard questions. I mean, doctors are people, too. And our job is to serve you and to try to do the best we can for you. And don’t be afraid to ask questions, and I think for someone who is dedicated to delivering quality and empathy, the answers will be… you’ll be able to read into the answers who your best pick is to fly the plane for you, as it were.
Jamie DePolo: How common is revision reconstruction? I’ve seen statistics on how many women decide to get reconstruction after breast surgery, but I’ve never really seen any statistics on revisions?
Dr. D: You know, I don’t have any national data to tell us… I don’t know that there’s any clearing house that tells us how many women have an operation that results in a deficiency of one variety or another, because as we talked about at the opening of our discussion, those deficiencies can be represented in a bunch of different ways. It can be chronic pain. It could be asymmetry. It could be scarification. It could be an overt failed flap. It could be an implant that extruded. It could be capsular contraction. It could be just about anything under the sun.
So I can only make a comment based on my somewhat distorted lens that I live in for the work that we do, mentioning before that we’ve become sort of a referral center for difficult and complex cases based on our history of doing a lot of this type of work over the years. But for the given week and the given month and year and so forth, of the 600 or 700 individual breast reconstructions we may do here, between 200 and 300 of them are a redo, a revision. So my experience is between a third and half of what I do in a week or a month is correction of a situation that didn’t work or didn’t work out or needs to be improved. So a lot. I guess the answer’s a lot.
Jamie DePolo: That’s much higher than I thought you were going to say, so that’s very interesting. But also at the same time good to know that if it’s that common that there are options for these people. So that’s great.
Dr. D: That’s the encouraging side of it. And you must remember as well, with respect to those numbers, again, my lens is distorted a little bit because many of the people who ring our phone are in that situation, reach out to us specifically for that. So that should be considered.
Jamie DePolo: Right. It’s not a random sample.
Dr. D: Right. Right.
Jamie DePolo: I have one last question for you. You kind of alluded to this earlier, but if a woman is looking for a plastic surgeon to do a revision, I know you talked about, “ask some hard questions.” Could you just give us a couple examples of some questions that you think are important to be asked of a surgeon before embarking on this surgery together?
Dr. D: Yeah. So I have some simple ones that give you a sense of the breadth of experience and the breadth of expertise. You would want to know, does that surgeon routinely do implant reconstruction? Do they routinely do AlloDerm-assisted implant reconstruction or acellular dermal matrix-type reconstructions? Do they have experience with reconstructions after nipple-sparing mastectomies?
Do they have experience with flap operations, and of those flaps, what kinds do they do on a weekly basis? Not “I have done one,” or “I have done some,” or “I have done quite a number of those.” You kind of want to drill down on those sorts of things and get a sense for in a given week, how many implant reconstructions would you say your team does and what types of flaps do you do on a weekly and monthly basis?
Do you do fat injection? Do you do all those sorts of things? Do you have a portfolio that I could review that show some of what a difficult situation might look like in terms of potential so that I can get some sense of what we’re talking about here in terms of approach and to give me a feel for what my outcome might look like? And, you know, even better than that, often a collection of patients who are willing to describe their experience with their journey with an individual practitioner? So some very basic things like that.
So just 1, 2, 3, and 4. Number 1, do you do implants? Number 2, do you do flaps and what kind? Number 3, do you have a portfolio of photographs that I can see? And number 4, do you have some patients I can talk to? And that will get you a long way down the road right there. And then the rest becomes getting a feel for how dedicated someone might be to going back in and undoing some difficult work or redoing some other surgeon’s product, that’s a whole echelon up in terms of dedication to the art. And if that practitioner doesn’t have an interest in that or they’re not accustomed to doing many of those, then they shouldn’t be asked to try to do it because it’s not in their wheelhouse. And so the patient would then move on to another practitioner for consideration. So interviewing an employee or interviewing anyone who you’re trying to determine whether they might be good to be partners with.
Jamie DePolo: That’s all very helpful. Thank you so much.
Dr. D: You’re very welcome. Thank you, Jamie.