Introduction

Since its development in 1966, bariatric surgery has become an effective modality for sustained weight loss. The growth of bariatric surgery has paralleled the burgeoning obesity epidemic in the United States.¹ Roux-en-Y gastric bypass has become the most effective and frequently performed means of sustained surgical weight loss, with mean weight loss at 36 months of 41 kg.^2,3 Other surgical procedures include biliopancreatic diversion, adjustable gastric banding, and the creation of a gastric sleeve.^4–6 Additionally, some patients are able to achieve weight loss with diet and exercise alone. Regardless of the means of weight loss, massive weight loss (MWL) is defined as weight loss of 45 kg (100 pounds) or more.⁷

Weight loss causes a multitude of both physiologic and anatomic changes. Severe volume loss results in skin redundancy and sagging, which can lead to issues with hygiene and the potential for infection. Song et al elegantly rated the anatomic changes that occur throughout the integumentary system after MWL.⁸ Additional consideration must be given to the nutritional status of MWL patients. Appropriate preoperative laboratory testing as well as consultation with a nutritionist may be advisable in these types of patients. The psychiatric changes that accompany MWL, and patient motivation for body contouring must also be considered when dealing with MWL patients.^9–13

After MWL the breast undergoes a unique set of changes not typically seen in other settings. The breast becomes deflated with a paucity of upper pole tissue. Extreme ptosis of the skin envelope and the nipple can develop, along with inferior malposition of the inframammary fold (IMF). The total amount of volume loss is variable among patients. The nipple areolar complex also often becomes displaced medially. The breast mound itself can be displaced laterally and the chest wall can take on an almost barrel-shaped configuration. Additionally, the skin envelope can become inelastic^14–16 (Fig. 14.1A–D). All these anatomic changes serve to make augmentation mastopexy, an already challenging procedure, even more intimidating.

FIG. 14.1 (A–D) After massive weight loss the appearance of the breast can be quite variable. Common findings on physical exam include a deflated and underfilled skin envelope, ptosis of the breast footprint, gland and NAC, unesthetic spreading of the areola, and medial translocation of the NAC.

Surgical restoration of the breast in these types of patients includes elevating and lateralizing the nipple–areola complex (NAC), elevating the IMF, restoring upper pole volume, and narrowing the wide breast. Additionally, excess axillary tissue should be excised when present to help better define the lateral border of the breast and aid in reducing fullness when the patient is wearing a brassiere.

The breast implant is a powerful tool that can aid in restoring volume to the deflated breast as well as re-establishing upper pole fullness for these patients. However, thoughtful surgical planning must be undertaken when using implants in the MWL patient. Conservative implant size should be considered, as MWL patients have unstable skin envelopes and may have recurrent ptosis if large implants are used. Some have advocated staging procedures for patients with severe ptosis to avoid potential complications such as compromise of nipple vascularity, and also to improve the predictability of the operation. Staging the procedure is a reasonable option for these patients; however, the cost must be factored into the decision, especially given that these patients often require revisionary surgery regardless of the approach used.

Overall, the breast deformity that can occur in MWL patients is extremely variable and challenging. The combination of parenchymal reshaping, strategically chosen skin patterns and volume restoration using a breast implant can be a useful tool set to address the entire deformity. Prior to any surgical procedure, preoperative preparation is essential to optimize outcome and ensure patient safety.

Preoperative Preparation

Proper assessment of the MWL patient begins with ascertaining the method of weight loss. If the patient lost weight through surgical means then determining whether the procedure was restrictive, diversionary or both allows the surgeon to determine what nutritional workup is necessary. Timing of the bariatric procedure and the starting weight at the time of surgery, the amount of weight loss since the procedure, the weight change in the past 3–6 months, and how long the patient has been at the current weight should all be ascertained. Generally, the patient should be at a stable goal weight for 3–6 months or more prior to any plastic surgical procedure. This usually occurs 12–18 months following the weight loss surgery.¹⁷

Preoperative assessment of the MWL patient must include a full evaluation of the patient’s nutritional status. This is especially important in patients who have undergone diversionary procedures, and to a lesser extent those undergoing restrictive procedures. MWL patients that were able to lose weight through diet and exercise generally have adequate nutrition and do not need supplementation. Whether or not supplemental Vitamin B12, iron, calcium, and/or multivitamins are being used should be noted, as deficiencies here can lead to altered wound healing. Baseline laboratory values should consist of a complete blood count, electrolytes, prothrombin/partial thromboplastin time, and albumin levels.⁷ Micronutrients may also need to be assessed in selected cases of possible malnutrition.^18–20

Physical examination of the MWL patient should focus on the quality of the skin, position of the inframammary fold (IMF), degree of NAC ptosis, the amount of gland remaining, and the quantity of axillary and lateral chest wall soft tissue excess. Often these patients have stretched out and inelastic skin with prominent striae that can create difficulties in shaping, wound healing, and maintenance of a long-term result. The degree of ptosis and the distance the NAC must be moved are considerations when an implant is used, as this variable can affect the vascularity of the NAC, particularly when an implant is placed under the breast. The existing amount of breast tissue must be taken into account when choosing an implant as this can affect the final volume of the breast. Often, despite the fact that a massive amount of weight has been shed, by the time the breast is lifted, there is a significant amount of tissue that can contribute to the overall breast volume. This must be recognized to avoid choosing an implant that is too big.

The position of the IMF is one of the most important issues in the MWL patient. The IMF is usually inferiorly displaced due to the weight applied to the fold when the patient is obese. This leads to the stretch of the chest wall attachments, and once the patient loses weight the deflated breast and IMF appear to have descended down the chest wall. Management of the IMF is one of the most difficult and potentially useful techniques in breast surgery of the MWL patient, if performed well.

Axillary and lateral chest wall soft tissue redundancy can be due to redundant skin and residual adiposity. Due to the poor skin quality and the excess tissue, recontouring this area is often best accomplished by direct resection. When performing resection it is important to consider future surgery the patient may have, such as brachioplasty and upper body lift. Additionally, control of the lateral breast pocket along the anterior axillary line must be respected during this resection. Loss of control laterally could lead to decreased patient satisfaction and increased likelihood of revision due to lateral implant malposition.

Mastopexy in the MWL patient is a technically challenging procedure and augmentation mastopexy adds an additional element of complexity. For surgeons not comfortable with augmentation mastopexy in MWL patients it is certainly reasonable to stage the operation. Generally, the mastopexy is performed first and the augmentation added at a later date. Occasionally, the patient may not even seek augmentation once the mastopexy has been performed. Regardless, it is important to discuss potential costs involved with the staged procedure.

Discussion of potential need for revision at the initial consultation helps mitigate some of the later issues that may arise when enhancements of the initial procedure are needed. Meticulous documentation of conversations regarding revisions is also important during the initial visit. Informing patients that scar length is commensurate with the amount of soft tissue resection allows the patient insight into the outcomes of the procedure. Additionally, discussion of recurrent ptosis, or the possibility of breast asymmetry is important in the augmentation mastopexy patient.¹⁴ Nipple viability and potential nipple loss must be part included as a potential risk during augmentation mastopexy. Establishing realistic expectations and goals for surgical outcome is an important part of a successful augmentation mastopexy procedure.

Preoperative Planning – Primary Augmentation Mammaplasty