Autologous Flap Use in Breast Reshaping after Massive Weight Loss

Published on 22/05/2015 by admin

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CHAPTER 42 Autologous Flap Use in Breast Reshaping after Massive Weight Loss

Siamak Agha-Mohammadi, Dennis J. Hurwitz

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Key Points

1. Massive weight loss (MWL) patients have a typical pattern of skin excess and laxity.
2. The skin is attached at the sternum and the vertebrae with the excess skin forming circumferential folds as the skin hangs off these zones of adherence.
3. Other areas of attachments such as the inframammary fold get stretched and the normal curves are attenuated and become linear.
4. Breasts in MWL patients are ptotic, deflated and often asymmetrical. The skin has lost all normal elasticity.
5. Various combinations of epigastric flaps, lateral thoracic flaps and variations of spiral flaps can be used to correct skin excess where it is not desired and used to augment the deflated breast.
6. These flaps can be combined with breast reshaping techniques and also with reverse abdominoplasty procedures.

Summary

Gastric bypass or massive weight loss (MWL) leaves a spectrum of changes and deformities that most patients find disturbing. The nature of the deformities is determined by the patient’s gender, age, pre-bariatric weight, the actual weight loss, and genetic predisposition of the patient. After MWL, many patients experience significant changes in the form, shape, and contour of their arms, upper thorax, back, abdomen, and thighs. Many of these changes follow a predictable course. As the patient loses weight, the upper torso laxity forms semicircular rolls with anterior attachments at the sternum and posterior attachments to the vertebral fascia. The intervening soft tissue hangs loosely as cascading rolls over the lateral chest and obscures the breasts. These staggered layers extend from anterior to posterior, dominating chest topography. Often the upper-back roll follows the breast tail of Spence over the lateral chest and then continues superior-medially towards the mid-back. The abdominal laxity is demarcated into smaller epigastric fullness and a larger suprapubic pannus by a variable transverse fascial attachment between the abdominal dermis and superficial muscular fascia. These adherences between muscular fascia and underside of dermis are associated with subcutaneous tissue atrophy.

However, the changes in the breasts and to a lesser degree, the buttocks, are less predictable. This is because, unlike the other tissues, the breasts are composed of both glandular and fat tissue, and a lattice of connective tissue ultrastructure.

Introduction

The degree of change in the breast shape and form depends on several factors that include:

1. The ratio of parenchyma to fat.
2. The nature and strength of the connective tissue lattice of the breast.
3. The weight and shape of the breast tissue.
4. The weight of the surrounding tissues of abdomen and back.
5. The zones of fascial adherence and integrity of the inframammary fold (IMF).
6. Post-lactation atrophy.

With massive weight gain, the expanding breast tissue adversely affects the skin dermal strength, as well as connective tissue stability. With MWL, typically, the breasts undergo mild, moderate or severe deflation. The dermal damage gives an atrophic quality to the breast skin. The IMF loses its semicircular form and becomes semilinear laterally due to the weight of the abdominal pannus, mid torso and back rolls, as well as the laxity of the underlying fascial attachments. The breast deflation thus appears more pronounced along the superior and lateral aspects of the breast as the IMF descends inferolaterally. Along with inferolateral displacement of the breasts, they also appear broadened by the loss of breast tail/lateral thoracic demarcation at the anterior axillary line. This results in flattening and loss of breast projection with mild, moderate or severe degrees of glandular ptosis. In addition, the nipple–areola complexes also become distorted and ptotic.

Many of the aforementioned changes occur independently on each side of the body and the degree of change is often asymmetrical. It is thus not surprising to find that the breasts are also asymmetrical in many aspects; most noticeably the shape and size. Compounding the breast deformity is the surrounding loose skin of the arm, axilla, chest and upper abdomen. The overhanging skin of the breast traps moisture with increased bacterial counts and bad odor. Skin irritation leads to intertrigo and sometimes deeper infections. Large pannus and ptotic regions may cause poor posture and back strain with pain.

Virtually all weight loss patients will require some form of a mastopexy procedure. This is often combined with either a breast reduction or a breast augmentation with prosthesis or autologous tissues. Since many patients have expressed aversion to silicone implant augmentation, we have been performing autologous breast reshaping using a variety of flaps for suitable candidates. We have found this approach an effective and safe strategy to aesthetically contour the breast and upper torso.

Aesthetic Correction of the Upper Female Body

The female physique is shaped in an hour-glass form. It is this form that should dictate our future endeavors in body contouring surgery. The breasts extend laterally as the breast tail of Spence up to the anterior axillary line to create lateral fullness and convexities. The breast completes a pleasing S-shaped contour from the abducted arm through the axilla through the IMF. It is important that this contour is recreated and aesthetically reconstructed in upper body lift surgery. This is best accomplished when the brachioplasty, upper body lift and the breast reshaping procedures are performed in tandem and are linked.

Breast Reshaping Strategies

The aim of body contouring surgery is correction of the lost shape and form. In the MWL patient a thorough understanding of the deformity and the patient’s desires need appreciation. Many MWL patients display loss of volume from their breasts. However, depending on their genetic make up, race, highest weight, and the lost weight, the amount of fatty and glandular volume lost from each breast may vary. For some, the breasts will be completely deflated whereas others will still have significant macromastia. In between these extremes, there are variable breast shapes and sizes. For those with existing macromastia and ptosis, we commonly perform a Wise-pattern reduction and mastopexy or dermal bra suspension technique as has been described by Rubin and Agha-Mohammadi.1 For others who require breast volume, we now commonly employ the excess local tissue for autologous augmentation.

Autologous Breast Augmentation

Patient selection

Today in our practice, an increasing number of MWL patients are requesting autologous breast reshaping. This is probably due to a combination of patient’s aversion for implant use, understanding local flaps available for breast reshaping in selected cases, improving technique and results, and the ability to serve the breast reshaping and upper body lift in union. Autologous breast augmentation is particularly suitable for those patients who have significant upper torso laxity in a vertical or circumferential direction or both. In these patients, a Wise-pattern mastopexy is needed to remove the excess atrophic skin of the breast in a vertical and transverse direction in combination with the upper body lift. Following inferiorly extended Wise-pattern markings of the breast, the skin within the markings is completely de-epithelialized over the lower breast pole and upper abdomen in preparation for autologous flap reshaping.

Operative technique – commonly used autologous flaps

Epigastric flap

In most cases, the upper abdominal tissue that resides below the IMF can be employed solely or together with the lateral thoracic flap or the spiral flap to augment the breast. When upper abdominal laxity is moderate to severe, epigastric flaps can be developed by performing a reverse abdominoplasty procedure on each side. The epigastric flap, which is continuous with the breast at the IMF, receives its blood supply through descending anterior and lateral branches of the intercostal vessels.

The preoperative markings are completed with the patient in the standing upright position. All anatomic landmarks are identified and marked (sternal notch, midclavicular point, meridian line, nipple–areola position, and IMF). Further, the expected position of the new IMF is marked over the sternum. The patient is marked for a reverse abdominoplasty by pinching and superiorly advancing the excess upper abdominal laxity. The epigastric flap is developed by de-epithelializing the skin in between the IMF and the reverse abdominoplasty incision. The lower incision of the reverse abdominoplasty is then extended through the subcutaneous tissue all the way to the anterior rectus fascia or the ribs. At this plane the epigastric flap is carefully and partially undermined toward the IMF. This tissue is relatively loose and mobile. Typically we fold the flap over the inferior breast parenchyma and secure it with interrupted stitches (2-0 Vicryl) as needed. The abdominal tissue is then discontinuously undermined and is raised all the way to the new IMF position. The abdominal tissue is then secured to the underlying costal periosteum using multiple (typically six) non-absorbable sutures (#0 Surgilon). In this fashion, the IMF is appropriately reconstructed. Next the Wise-pattern mastopexy procedure is completed.

The epigastric flap usually provides limited tissue for breast fill and is best combined with the lateral thoracic flap or the posterior thoracic flap. This combination is respectively called the Sickle modification or the Spiral flap, because of the geometry of positioning during breast reshaping.

Lateral thoracic flap

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