Key Points

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:

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

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

The lateral thoracic flap lies in the thorax between the anterior and posterior axillary lines. In MWL patients, this region is often prominent and lax. Furthermore, the breast tail of Spence loses its demarcation with the lateral thoracic region and flows as a transverse fold in continuity with the back. For those patients who have significant circumferential laxity of the chest with mild vertical back excess, a lateral thoracic flap can be developed as part of a vertical thoracoplasty. In combination with a reverse abdominoplasty, we refer to this flap as the sickle modification of the spiral flap.² The excess lateral thoracic tissue can be relatively extended to span over the thorax to the back. It represents all the tissue between the anterior axillary line and the posterior axillary line, which is further displaced posteriorly with weight gain and loss.

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, IMF, and the breast tail/lateral thoracic demarcation). The posterior marking of the vertical thoracoplasty is then drawn by pinching and advancing the circumferential excess up to the anterior axillary line (Fig. 42.1).

Fig. 42.1 Preoperative marking of a MWL patient for a L-brachioplasty, vertical thoracoplasty, reverse abdominoplasty, and Wise-pattern mastopexy.

Courtesy of Siamak Agha-Mohammadi.

The flap can be approached in two ways. It can be developed in a vertical manner by incising over the anterior and posterior axillary lines toward the lateral thoracic fascia. Roughly parallel vertical incisions are made through to the lateral border of the pectoralis major muscle and the anterior border of the latissimus dorsi muscle. The flap is then elevated from axilla along the anterior border of the latissimus muscle over the serratus muscle fascia towards its continuation with the epigastric flap. The lateral thoracic flap is then rotated medially and spiraled into a submammary pocket. Alternatively, the flap can be elevated in continuity with the lateral breast tissue. The vertical incision is made over the posterior marking along the anterior latissimus dorsi border. The flap is released proximally at the axilla. It is then raised by undermining the lateral thoracic tissue from the posterior incision over the lateral thoracic fascia toward the breast tail and up to the anterior axillary line. The epigastric and lateral thoracic flap crescent is undermined cautiously toward the breast parenchyma, leaving major perforator vessels intact when possible. The flaps maintain their blood supply via perforators through the serratus muscle and the breast parenchyma. They are then secured in place via absorbable sutures (interrupted 2-0 Vicryl) to create a breast mound (Fig. 42.2). The IMF is then reconstructed as for the epigastric flap. The back tissue is then advanced all the way to the anterior axillary line and is secured to the underlying serratus muscle using large bites of non-absorbable sutures (#0 Surgilon). The breast tissue is then approximated to the posterior thoracic tissue via interrupted Vicryl sutures. In this manner, the breast tail/lateral thoracic demarcation is reconstructed and the breast mobility and laxity preserved (Figs 42.3 and 42.4).

Fig. 42.2 Operative sequence of breast reshaping with epigastric and lateral thoracic flaps of the same patient as in Figure 42.1.

A De-epithelialized breast within Wise-pattern mastopexy region and over the epigastric and lateral thoracic flaps. B The upper marking depicts the epigastric flap and the lower marking depicts the lateral thoracic flap. C Both epigastric and lateral thoracic flaps are released from the abdominal and posterior back tissue respectively. D The abdominal tissue is discontinuously undermined to further mobilize the tissue.E The epigastric flap is undermined over the anterior rectus fascia and pectoralis fascia towards the IMF. F The lateral thoracic flap is undermined over the lateral thoracic fascia towards the breast tail. It is released superiorly from the axilla. G Non-absorbable stitches are used to elevate the abdominal tissue and advance the back tissue against the underlying costal periosteum. In this manner, the IMF is reconstructed in a more appropriate position. H Depicts the non-absorbable sutures under the epigastric and lateral thoracic flaps. I Advanced abdominal and back tissue against the underlying ribs. J The central breast flap is elevated and secured to the underlying pectoralis fascia using several stitches. K The lateral thoracic and epigastric flaps are folded against the central breast flap and secured with interrupted stitches. L Remodeled right breast. M, N Remodeled left breast.

Courtesy of Siamak Agha-Mohammadi.

Fig. 42.3 A Pre-operative picture of the MWL patient in Figures 42.1 and 42.2 presenting with breast asymmetry, upper body laxity and arm laxity. B Postoperative picture of the same patient at 2 weeks. C, D Postoperative pictures of the same patient at 9 months. Patient had an L-brachioplasty, J-thoracoplasty, reverse abdominoplasty and asymmetrical breast reshaping with sickle modification of Spiral flap.

Courtesy of Siamak Agha-Mohammadi.

Fig. 42.4 A, B Preoperative pictures of a MWL patient presenting with breast asymmetry, upper body laxity and arm laxity. C–E Postoperative pictures at 8 months. Patient had an L-brachioplasty, J-thoracoplasty, reverse abdominoplasty and asymmetrical breast reshaping with sickle modification of Spiral flap.

Courtesy of Siamak Agha-Mohammadi.

Spiral flap

For those patients who have moderate-to-significant degree of excess upper thoracic and back tissue in a vertical direction, the spiral flap will provide the most ample local tissue for autologous breast augmentation. The flap corresponds to the upper back fold that extends laterally over the chest and back and is typically excessive in those patients who have significant vertical upper torso laxity. The spiral flap takes advantage of the excess back tissue as a posterior thoracic flap in combination with the epigastric and lateral thoracic flaps.³ Use of this flap for autologous augmentation addresses both the issue of excess upper back laxity and breast volume loss. This dermoadipose flap is supplied through the posterior branches of intercostal vessels and branches derived from lateral thoracic fascia.

The spiral flap is particularly suited for those patients who have significant vertical laxity of the upper torso and significant loss of breast volume. The former characteristic typically presents as bilateral cascading lateral chest and back rolls. In these patients, the spiral flap is often combined with a Wise-pattern mastopexy. Similar to the lateral thoracic and epigastric flaps, 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 inframammary fold, anticipated new IMF position). The patient’s upper back roll in line with the breast tail is marked over the lateral chest and the back for excision. The markings extend from the midaxillary line transversely and converge medially as they approach the midback. The lower line is in continuity with the IMF or the lower incision of the reverse abdominoplasty markings. The upper marking is determined by pinching the excess back tissue while converging on the lower markings of the Wise-pattern mastopexy (Fig. 42.5). The size of the upper back roll is reflective of the volume of augmentation. The marked upper back roll is cut to the muscle fascia and then de-epithelialized from its apex towards its base at the midaxillary line while the patient is in a prone position. This defines the boundaries of the spiral flap.

Fig. 42.5 Preoperative marking of a MWL patient for a L-brachioplasty, vertical thoracoplasty, Spiral flap and Wise-pattern mastopexy.

Courtesy of Dennis J. Hurwitz.

The flap is then elevated with the fascia of the underlying latissimus dorsi muscle toward its base. Dissection stops just beyond the anterior border. The base of the flap is left intact in continuity with the breast tail over the lateral thoracic fascia. After the donor site is closed in two layers, the patient is turned supine. The upper incision is extended up to the anterior axillary line. A submammary pocket is meticulously created as a crescent under the upper aspect of the breast mound and extended medially to the medial apex. A large pocket should be avoided since it will result in a flat, pancake-shaped breast. The apex of the flap is then spiraled through the submammary pocket and is pulled medially at the medial edge. The flap tip is then sutured in place at the medial edge to the underlying pectoralis major fascia over the fourth or fifth costochondrium (Fig. 42.6).

Fig. 42.6 Operative sequence of breast reshaping with the Spiral flap.

A Development of left posterior thoracic flap component of the Spiral flap. B Elevation of the tight posterior thoracic flap over the lattissimus dorsi muscle. C Closure of the left upper body lift incision. D Development of the epigastric flap component of the Spiral flap on the patient’s right side. E Development of the submammary pocket for spiral flap accommodation on the patient’s right side. F Advancement of the Spiral flap into the submammary pocket on the patient’s right side.

Courtesy of Dennis J. Hurwitz.

In patients who have significant vertical laxity of the upper torso, we typically perform a reverse abdominoplasty together with a spiral flap. This is especially helpful. The epigastric flap can be utilized to further augment the breast as needed. It also enables us to reconstruct the IMF at a more appropriate position. In those patients who continue to have excess circumferential laxity despite the Wise-pattern mastopexy, a vertical thoracoplasty of the lateral thorax above the Spiral flap ensures appropriate upper torso tightening and re-creation of the breast tail/lateral thoracic demarcation. View accompanying DVD for video technique demonstration of the Spiral flap reshaping of the MWL breast.

Our experience with the use of this technique in bariatric patients has proved aesthetically pleasing in reconstructing the breast mound and correcting the upper torso deformity (Fig. 42.7).

Fig. 42.7 Postoperative picture of the patient in Figure 42.5 after Spiral flap breast reshaping, L-brachioplasty and upper body lift at 12 months.

Courtesy of Dennis J. Hurwitz.

Pitfalls and How to Correct

The use of autologous tissue for breast reshaping can be complicated by fat necrosis and asymmetry in volume and lateral IMF inferior pull. As the induration of the fat necrosis tends to resolve, no treatment is needed. Aberrant speckled calcifications on mammography have prompted needle biopsy in two patients and open biopsy in one of our patients. In rare cases of postoperative breast asymmetry, we have performed reduction of the larger breast or lipoaugmentation of the smaller breast as indicated. For lateral IMF descent, a revision and elevation of this structure may be needed in order to accomplish a semicircular IMF.

Postoperative Care

Postoperative care starts during the preoperative assessment of the MWL patient. All patients are cleared medically for the procedure, with chest X-ray and ECG and regular laboratory parameters as needed. In addition, we pay special attention to the patients’ nutritional deficiencies and obtain laboratory tests for total protein, albumin, prealbumin, vitamin A, vitamin B₁₂, folate, and homocystine levels. All patients are placed on a perioperative nutritional supplement designed specifically for enhanced recovery after surgery.⁴ Patients are encouraged to donate autologous blood when possible for larger cases. There is no special postoperative care for breast reshaping than for that treating the whole body contouring patient. We do not usually use drains with these procedures. Patients are typically placed in a lightly compressive breast dressing for about 2 weeks. Heavy lifting and exercise is prohibited for about 4 weeks. Special attention is paid to appropriate hydration, transfusion, ambulation and use of sequential pneumatic compression stockings.

Discussion

The breast deflation, Cooper’s ligament laxity, loss of skin elasticity, and alteration of the three-dimensional breast connective tissue ultrastructure results in variable degrees of glandular and nipple areola ptosis. In MWL patients, the underlying deformities of the breasts are deflation and severe ptosis. Breast ptosis, as described by Regnault,⁵ is due to a discrepancy between breast volume and the overlying skin envelope. A variety of procedures have been employed in plastic surgery to rejuvenate the aging ptotic breast population. Surgical correction consists of increasing breast volume, reducing the skin envelope, or a combination of both in the form of an augmentation/mastopexy.^6–10 Many of the described techniques are best suited for small to medium sized breasts of the aging population, including Benelli’s periareolar incision,¹¹ Regnault’s B technique,⁹ cirumvertical incision,¹² Lejour’s vertical incision,¹³ and Wise-pattern incision procedures.¹⁴ Even though these procedures produce enhanced projection of the assembled breasts, the younger postbariatric patient with MWL poses new challenges that require an alternative approach.

With massive weight gain both upper and lower body accumulate fat depositions that are not only dependent on the amount of calorie intake, but also determined by age, gender, and genetic predispositions of the patients. In addition, the patient’s tissue quality and zones of adherence play an important role in confining the local fatty depositions. In the upper body, hypertrophy of the fatty tissue results in a three-dimensional expansion of the subcutaneous tissue layer of the upper torso. This results in stretching of the superficial fascial system and dermal breakage of skin to a varying degree. Consequently, zones of adherence and demarcations become loose and the skin develops striae. MWL often results in dissolution of fat in the subcutaneous layer. Hence, the subcutaneous tissue becomes loose, deflated and sagging due to irreversible loss of the superficial fascial system and dermal elasticity. In the upper body, the deflated tissue appears as cascading rolls that extend from the sternum to the vertebral column.¹⁵ The breast deformity is also complex. The patients not only have severely ptotic breasts, but also the breast volume is unevenly lost resulting in flat pendulous breasts. Furthermore, the remaining overstretched breast skin is often significantly excessive and is of poor quality due to many cycles of expansion and reduction. Often, these patients require complete reshaping of their breasts to a rounder form as well as a breast lift. Postbariatric patients typically present with variable and asymmetric degrees of volume loss from each breast. The breast reshaping procedure includes some form of mastopexy with or without breast reduction or breast augmentation; depending on the volume lost and the patient’s desire.

Breast reshaping is thus best performed as part of the upper body lift procedure to correct both the pendulous breasts and adjacent lax tissue. Also, in this manner, the adjacent local tissue can be utilized for autologous breast augmentation if needed. Reshaping of the breasts requires a combination of remolding and mastopexy. The goals of any breast reshaping include: (1) appropriately placed scars, (2) stable results, (3) good position and projection of the reshaped breasts, (4) reduced complications, and, most importantly, (5) ensuring blood supply and innervation to the nipple–areola complex.

In our practice, we have routinely employed the use of local excess tissue as epigastric, lateral thoracic, or combined as the spiral flap in providing autologous breast tissue for breast reshaping in an efficient and safe manner in the course of an upper body lift.