Revision Surgery: Why It Happens (And How to Avoid It) (Ep.111)

Dr. Jason Hall:

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Believe it or not, one of the most common consults I see isn't for first time plastic surgery, it's for patients who have already had surgery and now they want a different result, or they want their previous results improved. The reality is that revision surgery is probably some of the most difficult surgery in cosmetic plastic surgery, and it isn't really talked about very much. Most surgeons don't talk about revision surgery a lot on the internet. So today we're going to talk about why revision surgery happens and what you the patient should know before your first surgery to hopefully prevent needing a revision. You so welcome to the Trillium show, where we talk about the ins and outs of the cosmetic industry, and I help you decipher all the junk that's out there that's filling the internet and your social media feed. The goal here is to make you a more informed consumer and not fall for all the marketing hype which our industry is famous for. I'm your host, board certified plastic surgeon and author of the book The Art of aging. Dr Jason Hall, so before we get talking about revision surgery, why it happens, and how to prevent it, let's kind of define it so revision surgery is a second procedure on a body part you've already had operated on to correct or improve a previous surgery. Result and revision surgery can happen after any procedure. It can have to have for breast augmentation, rhinoplasty, face lift, breast lift, Tummy Tuck, liposuction, any procedure that we do may need to be revised. And I think going into this, it's important to know that because you want or need a revision surgery doesn't mean that the surgeon who did the first surgery did something wrong. A lot of times it isn't. Why might you need revision surgery? Well, people heal differently. Expectations change. One thing that that people don't really take into account when we're talking about revision surgery is that aging happens to everybody, whether you want it to or not. And so let's break revision surgery and the need for revision surgery into really three major categories. We'll talk about biology, we'll talk about poor planning, and then we'll talk about expectations. So the first category that we'll talk about is biology, and I'll include aging in the biology section after surgery, the thing that we cannot control, even though we like to try, is the healing process. And for things like rhinoplasty, face lift surgery, breast lift surgery, especially if you're using an implant, aging can change what was a great result into an okay result over time, whether you want it to or not, and it's not uncommon 1015, years down the road, especially if you've had major weight fluctuations, pregnancy or just as the result of time that something that once looked great doesn't look that great anymore. The other part of the biology that we need to talk about is just genetic factors, healing differences, differences in skin elasticity, scar tissue, all of these things can change. A What is initially a great result to a year, two years, five years down the road, a result that's not quite as great. A good example of this is capsular contracture after a breast augmentation. Now, capsular contracture is, you know, the published rates for that or about 5% so five out of every 100 women that have a breast augmentation are going to get a capsular contracture, and usually that means revision surgery. You add a breast lift to that, where we're counting on tissue that is stretched and floppy to start with, you're trying to build something out of that, and that can relax over time and cause that breast to need to be tightened up a little bit down the road. Is that surgeon's fault? Not at all, but it's something that can happen. I think it's important to know going into any of these procedures that the aging process and biology is something that we can't control and something that may merit revision surgery down the road. The second thing that can contribute to the need for revision surgery later is poor surgical planning, and this unfortunately. Is more common than I think people realize. Examples of poor surgical planning can be choosing an implant that's way too large for your soft tissue or for your frame skin tightening or soft tissue tightening that isn't quite tight enough faces that have too much fill or too much fat. Those are things that happen well before the surgery, and are things that largely rest with that discussion between the surgeon and the patient in consultation to try and correct now some of this, you know, we talked about choosing implants that are too large, that happens, especially now with Instagram and social media, that happens quite a lot. There are things that we can do to minimize the impact of an implant that's too large, creating the need for revision surgery later. But it's important going into the operation to understand that if you want an implant that's a little too big, your risk for revision is going to be higher, and the procedure itself is going to need to be a little bit different to try and prevent that. So planning and then execution is a crucial thing to take into account when you're considering plastic surgery and wanting to minimize the need for revision surgery in the future. A third reason for revision surgery is a mismatch between a patient's expectations and what a surgeon's target is for that result consultation is where the surgeon and the patient discuss what problems are, what goals are, and then design a solution together to help the patient meet the goals that they're trying to achieve. What happens sometimes is that those expectations don't align, and it's largely a communication problem that is another reason why the consultation is such an important part of cosmetic surgery, and really shouldn't and can't be rushed, and certainly can't be delegated to somebody who's not the surgeon themselves. The reality here is that a revision is necessary, not because of the operation, but because of the communication between the patient and the surgeon and the expectations that weren't aligned from the outset. Revision surgery itself is a lot more challenging than doing a surgery the first time. It involves scar tissue. It involves anatomy that's altered. It involves blood supply that's different from what it was before the first surgery, and typically comes with much less predictable healing and a higher risk of having complications after surgery than the initial surgery. Good example of this is redoing breast surgery, specifically breast lift surgery, where the nipple itself has been moved around a little bit to center it back on the breast. Well, when that breast and nipple position changes over time, or changes as the result of healing, and we find ourselves needing to move that nipple again. That blood supply has already been disrupted. It's already been changed, and even if you know where the blood supply is coming from, sometimes the fix has to involve cutting through some of that blood supply to get the result that we're looking for. That means healing can be much more dangerous and difficult, and the risk of something not healing well, or in the worst case, the nipple dying, is a lot higher. And so it's important to really discuss that and to know what we're getting into before surgery, so that we can take steps to prevent complications on the back end, and that everybody's expectations are aligned. Sometimes that means not doing surgery at all. Sometimes that means with the discussion between the surgeon and the patient, taking a low but calculated risk that things are going to heal the way we want them to. You know, a good analogy with all of this is that, you know, plastic surgery is kind of like remodeling your house. You know, we're taking something that that looks good and we're making it better. Revision surgery is kind of like remodeling your house after a hurricane has gone through. You know, nothing's in the right place. We're trying to put things back where they should be and make them look better than they. Do now, but we're dealing with things that have that have already been, you know, irreparably altered by what's happened before. What you don't hear about revision surgery is that there are a lot of surgeons out there that don't do revisions. They refuse to because of the risks, the healing risks, because of the usually lengthy discussion that takes place during the consultation, a lot of surgeons just won't do revisions. Some surgeons will only do revisions of work that they previously went because they know what they did in the past. They know exactly what they did in the past, and will only revise procedures that they've already they did the first one, and that, you know, some patients don't like what they have to hear from the first surgeon and go shopping and bounce around from surgeons, a surgeon looking for a better result with each procedure. And you know, you can get a beautiful result with revision surgery, but it's really challenging, very challenging. The other part of revision surgery that we have to talk about is the psychological part of it. Now this is where we'll kind of break, I'll kind of break revision surgery into two different categories. You've got revision surgery on one hand, and then you've got secondary surgery on the other hand. Secondary surgery is kind of surgery that we're redoing as a result of aging. Things have gotten loose, things that, you know, breasts have drooped after, or lift with implants. You know, those are what I consider secondary operations, revision surgery, on the other hand, is when something goes sideways, the result you don't like, as a result of a complication, as a result of an error in judgment, as a result of a technical problem, and we're having to revise something that didn't go the way we wanted to for reasons other than just time and age, those are actually the more challenging ones for the patient, because there's often a lot of emotional stress that comes with revision surgery. There can be distrust in a surgeon if you had a complication and you felt abandoned. And there can also be sort of an unrealistic expectation that we can turn back the clock and go back to what things looked like before the first surgery, which we can't. And so for a lot of those reasons, you know, there are a fair number of surgeons who just don't do revision surgery at all. You know, a surgeon that does revisions has to, has to manage both of those things, has to manage the surgery and the and the changes that are inherent in the anatomy there, and also has to manage the psychology of both themselves and of the patient that's looking for a revision surgery. So how can you reduce your risk for needing a revision? There are a couple of things. Is one, you've got to accept that biology and age matters. It happens. Not everybody's soft tissue is the same. Not everybody ages the same, and there are going to be changes as a result of those factors that nobody can control. You want to look for a surgeon that does revision surgery regularly, and then during the consultation, talk to them about results. Talk to them about expectations, talk to them about what limitations exist before you go down and have a second or third or fourth procedure. And then you also have to understand that revision surgery, just from a financial perspective, isn't the cheapest revision surgery always costs more than the first surgery. Sometimes that cost can be substantially different just because of the technical demands of the surgery, the time that it takes to do revision surgery, and the risks that are involved with surgery. You know, the takeaway here is that the best revision surgery is the one you don't need. Is the one you never need. Every decision that's made up to surgery matters. The consultation matters, the rapport between you and your surgeon matters. And so think about those things carefully when you're sitting down and planning your first surgery, so that hopefully we're not sitting down, you know, a year, two years later, talking about the need for revisions. I'm interested in comments on this one. This is not a topic that we talk about a lot, so any comments, any questions, leave a comment below, shoot me a DM on Instagram at Dr. Jason hall.com, thanks, and look forward to the next show you.