Revision surgery (cratering, tethering, etc)

[joe7]

I'd like to know how any doctors here would approach this revision. I have the following issues:

1. Breast tissue still remaining towards the armpit (pic 1)
2. Crater deformity on right areola (pic 2)
3. Tethering + contour deformity on left side (pics 3&4)

[Litlriki]

It would be helpful to know a few items and see some better photos.  When was your surgery? What was done? Advise regarding pre-operative appearance.  If you could post photos that were comparable to standard photos in a relaxed position and then add the photos with flexion, etc. to clarify your concerns. As you've posted, it's very difficult to really say anything about how to revise. 

[Dr. Elliot Jacobs]

Agree that there are contour irregularities -- some residual tissue in certain places and cratering in other places.  It would be wise to wait a minimum of six months before considering any revision.  Then, you should first return to your surgeon for his opinion on what to do.  You might also want to visit at least one other gyne specialist to get a second opinion.

All is not lost.  If you look like this six months or more after surgery, you can probably achieve improvement with addition lipo of the residual tissues and fat flap reconstruction (my preferred method) to deal with any cratering and tethering.

Dr Jacobs

[joe7]

Thank you both for your input. Unfortunately, this is 10 months post op. I don't trust my original surgeon, so I will most likely contact somone else who is experienced with revision surgery.

I might try getting very lean first before considering a revision. I actually gained a lot of fat after surgery, could this have made my results worse?

[Dr. Elliot Jacobs]

Yes, it is possible that your post op results could look worse if you gained weight.  Reason:  the areas with residual tissue (fat) would enlarge while the areas where too much tissue has been removed would not change that much.

On the other hand, if you feel you are headed towards revision, then having that extra fat may be helpful -- it will provide sufficient tissue to perform fat flap reconstruction of the craters.  If you are too lean, the fat flaps would be lean too and may not be of sufficient bulk to do a proper reconstruction.

Dr Jacobs

[joe7]

Dr Jacobs, I noticed that you are one of the few doctors who suggests fat flaps rather than fat grafting. Given the poor success rate of fat grafting, why do so many doctors keep using it as the default answer for cratering? Is the fat flap procedure more difficult or specialized than fat grafting?

[Dr. Elliot Jacobs]

Fat flaps are more difficult and technically demanding than fat grafting.  However, I am convinced that the results obtained on the operating table are the long term results as well. In essence, one and done. 

Fat grafting is simpler to do and the initial results may look good.  But most doctors will agree that there is always some loss of the grafted fat (which turns into scar tissue) and that oftentimes two or even more fat grafting operations are needed for best results.

Just my humble opinion.

Dr Jacobs

[joe7]

Appreciate your input, thanks again. It's a shame there aren't more surgeons who perform the fat flap surgery.

I've decided I will get leaner first and see if it helps. My waist actually went from 32 pre surgery to 38 after a few months post surgery. Since I gain fat mainly on my chest (and  lower belly), it's likely this has negatively affected the results. I'll post back here when I'm back to my original 32 waist.

[Litlriki]

I caution my patients about coming in for their surgery "too lean," generally meaning contest condition among the bodybuilding crowd. As Dr. Jacobs pointed out, it's actually better for you to be a little fatter for the surgery and get leaner afterwards. I think you're wise to assess your results in a leaner condition, but if you proceed with revision, I'd encourage you to loosen up on your diet and have the surgery at a point where you'd be comfortable living (body-fat percentage-wise).  

[joe7]

That's great info, thank you Dr. Silverman. I always thought the leaner the better but clearly that isn't true.
I was about 12-15% body fat at the time of surgery, and unfortunately went to about 20%+ in the months post op. I'd like to get down to about 12% again, which is quite a healthy and sustainable percentage, though I may end up dieting into single digits at some point. I suppose if I want a revision at that point then I can always put a little fat back on before the surgery.

[Litlriki]

If you spend most of your life at 12% and can maintain that without killing yourself, it's okay to have the revision surgery there.  But if that 12% BF is a chore, you should do the surgery at a more comfortable weight.  Getting leaner thereafter will likely help the appearance, whereas getting fatter after a nice result is obtained could still lead to contour issues.  

[Dr. Schuster]

I agree with the others in general but with some additional comments. I find it difficult to tell from your photos exactly what is gong on. You appear in the photos to be very lean. Therefore the enlerged areas may in fact be areas which were previously under treated. I also can't really tell if your thinner skin is really stuck, or retracted either at rest or during movement. For minor cases needing revision I have found that fat grafting can be extremely successful, even if you had to repeat it twice.