Revision Breast Reconstruction

Revision breast reconstruction is surgery to correct a reconstruction that did not turn out as it should — a breast that hardened or became painful after radiation, implants that sit unevenly or too high, a flap that lost volume, a 'flat closure' that was left with folds and dog-ears, or a result that simply never matched what was promised. It is some of the most demanding work in breast surgery, and restoring patients left with poor results elsewhere is a large part of Dr. Wai-Yee Li's practice. Many of the women who come to LA Breast & Body in Pasadena and Arcadia have already had one, two or more operations elsewhere, and a good number are referred by other surgeons.

Dr. Li's approach begins from a simple principle: the second reconstruction has to be planned around what the first one left behind — the scars, the radiated skin, the missing tissue, the capsule around an implant — instead of repeating the same operation and hoping for a different result. Her decade at a busy cancer center, her PhD in wound healing, and her own published refinement of the latissimus flap give her more than one way to solve these problems.

Problems Dr. Li corrects

Revision covers a wide range of situations, and the first job of a consultation is to name yours precisely. The problems Dr. Li sees most often include:

• Capsular contracture — scar tissue around an implant that has tightened, so the breast feels hard, looks distorted, rides high, or aches, often after radiation
• Implants that are asymmetric, malpositioned, rippling, or visibly out of proportion with the other breast
• A ruptured or aging implant that needs to be removed or exchanged
• Reconstructions left unfinished — tissue expanders never exchanged, or a breast rebuilt without a nipple
• Radiated implant reconstructions that have failed and need healthy tissue brought in
• Previous flap surgery that has lost volume or shape, or an abdominal flap that left weakness or a bulge
• Aesthetic flat closure that was not flat — folds, dog-ears and residual tissue that do not feel like the closure you asked for
• Delayed reconstruction for women who were told, sometimes years ago, that nothing more could be done

Several of these overlap. A radiated breast with a contracted implant, for example, is usually best treated by removing the implant and capsule and bringing in non-radiated tissue and not by exchanging one implant for another.

How Dr. Li rebuilds after a failed implant reconstruction

When an implant reconstruction has failed — through contracture, infection, radiation damage, or thin tissue that never covered the device well — the answer is often autologous tissue. Radiated skin does not heal reliably and does not soften, so the standard of care is to bring in healthy tissue from elsewhere. Dr. Li's tool for this is the Combined Bra-Line Back Lift Latissimus Flap, her refinement of the LAT flap in which the back scar is placed horizontally along the bra line, where it stays hidden in most cases, and any excess back rolls are removed through the same incision.

The flap can be fully autologous when there is enough back tissue, or combined with a new implant for volume and a lifted upper breast. Because only one side of the back is used for each breast, it remains an option even after other reconstructions have been spent.

Having performed abdominal flaps for years, Dr. Li no longer offers them: her latissimus patients recover faster and do better over the long term, and she has repaired the hernias and abdominal weakness that some abdominal-flap patients were left with. Where an implant is still the right choice, she may move it from beneath the chest muscle to the 'prepectoral' plane in front of it, which in her experience is associated with less capsular hardening, particularly after radiation. Her BLBL-LAT flap gallery includes delayed reconstructions.

Implant problems: exchange, removal, or something else

Not every revision needs a flap. A contracted capsule can be released or removed and the implant exchanged; a ruptured silicone implant can be taken out cleanly with its capsule; asymmetry can be corrected with a different size, shape or position, sometimes with fat grafting to soften edges and refine contour. Some women decide they are finished with implants altogether, and Dr. Li performs implant removal with a lift or fat grafting so the breast keeps a shape they are happy with. If you suspect a silent rupture, her breast implant rupture page explains the signs and the imaging she uses to confirm it.

Flat closure revision

Aesthetic flat closure is a reconstruction in its own right, and it is harder to do well than it looks. Dr. Li is regularly asked to revise closures performed elsewhere that left the chest with folds at the sides, dog-ears under the arms, or a contour that does not feel flat to the woman living with it. Revision removes the residual tissue and redrapes the skin so the chest is smooth and comfortable. Her aesthetic flat closure page and the video below describes what patients have experienced and how she corrects it.

Finishing a reconstruction

Some revisions are about completion more than correction. Expanders that were never exchanged can be replaced with the final implant or with a flap. A reconstructed breast can be brought into symmetry with the other side — a lift, reduction or augmentation of the natural breast is a normal part of reconstruction, not a cosmetic extra. And nipple and areola reconstruction, including 3D nipple tattooing, is often the step that makes a rebuilt breast finally feel like one.

What recovery looks like after a revision

Recovery depends on what is done. An implant exchange or capsule removal is often a same-day procedure with drains and a light surgical bra; since no two revisions are alike, Dr. Li sets your recovery timeline with you at consultation. A flap reconstruction is performed in hospital: the day after surgery Dr. Li and her team check on you, you are able to shower, and an occupational and physical therapist teach you how to move without straining the repair.

The back scar from a bra-line back lift flap is closed with buried dissolvable stitches and sealed with skin glue, so it needs no dressing. Dr. Li uses long-acting nerve blocks during surgery so that the first days are sore, not painful, and her patient resources pages set out drains, activity and follow-up in detail.

Because revision patients have often been through radiation, chemotherapy or several operations already, healing is planned more carefully than for a first surgery. Smokers are asked to stop at least six weeks beforehand, blood sugar needs to be well controlled, and the timing is set around any ongoing cancer treatment. None of this is unusual for Dr. Li: it is the setting she worked in every day for a decade.

Is revision reconstruction covered by insurance?

Often, though it is usually decided case by case. The federal Women's Health and Cancer Rights Act requires most health plans that cover mastectomy to cover reconstruction, procedures on the other breast to produce symmetry, and treatment of physical complications — which is where much revision work sits. What your plan will approve, and for which surgeon, depends on the plan.

Dr. Li is not a Medicare provider and is not in network with any commercial insurance. In many cases she and her team can work with commercial PPO plans as an out-of-network surgeon, on a case-by-case basis, and some of her patients choose to pay directly for revision surgery because they value her skill, expertise and care. Bring your insurance details, your operative reports and any imaging to the consultation, and our team will tell you what is realistic before you decide anything.

A second opinion before you commit

If another surgeon has proposed a revision plan, Dr. Li is happy to review it. Several patients have avoided complications on the strength of that reassessment and an improved plan; some have surgery with her, and others take her recommendations back to their own surgeon. Your records stay in our HIPAA-compliant system and are not shared without your consent.

Your revision consultation in Pasadena

Revision consultations are longer, because the history matters. Dr. Li will want to know every operation you have had, when any radiation was given, what implants are in place — bring the implant card if you have it — and, above all, what is bothering you and what you would consider a good result. She examines you, photographs your chest for your chart, and then explains the options that fit your anatomy, with photographs of similar cases so that the plan is concrete, not abstract. Partners and family are welcome, and LA Breast & Body is an all-female practice built so that women feel comfortable being seen and heard.

Getting to us from Pasadena, the San Gabriel Valley and beyond

Dr. Li's Pasadena office is at 675 South Arroyo Parkway, Suite 310B, a few minutes from Old Pasadena and Huntington Hospital, and her Arcadia office is at 624 West Duarte Road, Suite 101a, on the 210. Patients come from Pasadena, South Pasadena, San Marino, Altadena, Glendale, Alhambra, Monrovia and across Los Angeles, and many travel from further afield; our out-of-town patient page explains how that works. A South Pasadena office is coming soon. Call or text 626 888 9728, or request a consultation online and tell us the best time and way to reach you.