Breast reshaping after massive weight loss, implant based

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Chapter 14 Breast reshaping after massive weight loss, implant based

Dennis C. Hammond, Shannon D. Armstrong, Michael Loffredo

Key Points

• Staging may be appropriate for extremely large or ptotic patients.

• The circumvertical approach is a powerful tool for management of the redundant skin envelope.

• Controlled management of the IMF is key to reducing the number of later revisions.

• Use of an implant can be an excellent adjunct for restoring upper pole fullness.

• Patient education regarding the complex and in some ways potentially imperfect nature of the surgical correction can aid in helping patients understand the potential need for future revisions to obtain the optimal result.

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 inelastic14–16 (Fig. 14.1A–D). All these anatomic changes serve to make augmentation mastopexy, an already challenging procedure, even more intimidating.

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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

Incision

Access to breast is generally provided by the incisions used to accomplish management of the redundant skin envelope. For periareolar approaches, this includes the inferior half of the periareolar incision. For circumvertical approaches, access is obtained through the vertical component between the bottom of the areola and the IMF. In either instance, access to either a subglandular or subpectoral pocket is readily obtained to allow accurate pocket dissection and placement of the implant.

Pocket

For many patients, the anatomic footprint of the breast has descended so far inferiorly that any attempt to create a subpectoral pocket will simply serve to cover only a small portion of the upper portion of the device secondary to the inferior breast malposition below the normally positioned pectoralis major muscle. In these circumstances, only minor advantage is afforded by attempting to position an implant under the muscle. For this reason, the subglandular plane can be an attractive option for these types of patients. The pocket dissection can be easily controlled and by removing the complicating interaction of the released pectoralis major muscle from its attachments to the overlying breast, one more variable potentially affecting the final result is eliminated, resulting in a simpler procedure. Also, by the time the ptotic breast is tightened and repositioned superiorly, the peripheral margins of the breast become softened, allowing the subglandular position to be used without risking undesirable implant show peripherally and in particular along the superomedial border. The potential for breast animation is also eliminated by using the subglandular position. These advantages must be balanced against the desire to avoid interference with postoperative mammographic evaluation of the breast and, as well, the risk for capsular contracture must always be taken into consideration. For patients who do not have a significant inferior malposition of the breast footprint, the partial subpectoral position with variable release of the inferomedial aspect of the muscle can be used, as would be done in any other breast augmentation procedure.

Implant

It must be realized that MWL patients have a very loose breast skin envelope and accurate pocket dissection can be challenging. Despite what appears to be very conservative pocket development, overdissection can very often be the end result. For this reason, it is recommended that round implants be used in an attempt to limit the potential for implant rotation that can be associated with anatomically shaped saline or cohesive silicone gel implants. Such devices can be used; however, great care must be taken in positioning and securing these implants into position. Utilizing round implants eliminates the potential for this complication to develop. Beyond this, all of the same considerations regarding the advantages and disadvantages of smooth versus textured devices as well as saline versus silicone gel implants are just as pertinent in the augmentation/mastopexy patient as they are in the primary augmentation patient. It is left to each surgeon to factor these variables into the decision making process to identify the best approach for each individual patient.

Surgical Technique

Primary Augmentation Mammaplasty

The patient is marked in the standing position with her arms resting gently at her sides (Fig. 14.2A, B). Basic landmarks including the IMF, midsternal line, and breast meridian are marked. The IMF line is communicated across the midline to allow the level of the fold to be identified without the need to manipulate the breast. In the midline, measuring up from the IMF, a distance of 4–6 cm is measured and this point is then transposed in a parallel line over to each breast meridian. This point represents the top of the periareolar pattern. Extending inferiorly, an oval is then drawn around the medial, lateral, and inferior aspect of the existing areola to complete the periareolar pattern. In the vast majority of cases, a vertical skin takeout will also be required to appropriately reduce the redundant skin envelope and lift the breast. The amount of skin to be resected can be estimated by pinching the inferior aspect of the breast below the NAC together until a pleasing shape is created. The medial and lateral aspects of the skin pinch are marked and carried down to the IMF, curving laterally as needed to create a contoured closure (Fig. 14.3A, B).

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FIG. 14.2 Preoperative appearance of a 52-year-old woman in preparation for augmentation mastopexy after losing 45 kg (100 lbs) following gastric bypass.

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FIG. 14.3 Final marks showing the top of the periareolar pattern being positioned a full 6 cm above the inframammary fold line seen extending across the torso from side to side.

The proposed vertical takeout is noted to curve slightly laterally as it extends down to the inframammary fold. This maneuver prevents bunching and potential wound healing problems from occurring at the level of the IMF after final closure. The exact dimensions of the vertical excision will be determined intraoperatively once the final implant is in place.

At surgery, the procedure is begun by accessing it through either the periareolar or vertical incision and the desired pocket is created, with care being taken to preserve the attachments of the IMF and avoid disruption of the dominant second intercostal perforator in the superomedial portion of the breast (Fig. 14.4). An implant sizer is then placed to create the desired volume. The skin envelope is then plicated together with staples to create the desired shape. For periareolar approaches, the proposed periareolar opening is stapled down according to the preoperative marks. For circumvertical approaches, the vertical incision is plicated together until the desired lower pole contour is created and then the periareolar portion is added. With the patient upright on the operating table, the shape and symmetry of the result is assessed (Fig. 14.5). Further plication or lifting is performed as needed to create the desired result. The patient is laid back down and the plicated edges are marked with a surgical pen and the staples are removed (Fig. 14.6A, B). With the areola under maximal stretch, a 40 mm areolar outline is marked with the aid of a circular template (Fig. 14.7). The areolar and periareolar incisions are made extending just into the superficial dermis and the redundant skin outlined by the marks is de-epithelialized along the periareolar and vertical segments (Fig. 14.8). The dermis around the periareolar incision is divided 5 mm away from the incised skin edge to create a small dermal shelf that will eventually hold the purse string suture. The edges of this shelf are undermined slightly to allow a contoured periareolar closure to be accomplished without excessive tissue bunching around the incision (Fig. 14.9A, B). With the skin and parenchyma now completely prepared for final closure, the chosen implant is inserted into the pocket. An iodoform occlusive drape is applied to the skin, with a small opening being made in the area of the skin incision. This prevents the implant from contacting the skin during insertion, thus minimizing the potential for bacterial contamination of the implant or the pocket. In circumvertical cases, the vertical segment is now closed (Fig. 14.10). The periareolar defect is managed using the interlocking Teflon suture technique.21 A PTFE suture on a straight needle is passed, joining eight evenly spaced points in both the areolar and periareolar incisions, spanning the intervening areas on the periareolar side by passing the suture in the dermal shelf. Pulling this smooth, strong and permanent suture together in a secure purse string type fashion allows control of the size and shape of the periareolar defect (Fig. 14.11A–C). A little trimming of the de-epithelialized edges to create a perfectly round shape with the final suturing completes the procedure22–27 (Figs 14.12 and 14.13).

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FIG. 14.4 Care is taken to preserve the attachments of the inframammary fold both medially and laterally to prevent inferior implant malposition postoperatively.

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FIG. 14.5 Appearance after both sides have been plicated. A 275 cm3 moderate profile plus sizer has been placed in the left breast and a 300 cm3 sizer on the right in an attempt to correct the patient’s preoperative volume asymmetry.

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FIG. 14.6 (A) The plicated edges of the proposed vertical incision are marked with a surgical pen. (B) With the staples removed, the final dimensions of the vertical takeout can be seen. The access incision for pocket dissection falls within this vertical segment.

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FIG. 14.7 With the aid of a circular template, a 40 mm diameter areolar mark is made centered on the nipple.

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FIG. 14.8 The periareolar and vertical segments are de-epithelialized.

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FIG. 14.9 The dermis around the periareolar incision is divided, leaving behind a 5 mm dermal shelf into which the purse string suture will be placed.

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FIG. 14.10 Appearance of the breast mound after closure of the vertical segment.

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FIG. 14.11 (A) A Teflon, polytetrafluorethylene (PTFE) suture attached to straight needle is used to control the periareolar defect. This material is strong, permanent, and smoothly slides through the tissues without catching or bunching. (B) The suture is passed in such a way as to approximate the 8 cardinal points of the areolar and periareolar incisions. (C) Appearance of the periareolar defect after the purse string suture has been cinched down.

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FIG. 14.12 Final immediate postoperative appearance.

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FIG. 14.13 Early postoperative appearance of the patient after the placement of a 275 cm3 moderate profile plus smooth round silicone gel implant on the left and a 300 cm3 implant on the right.

The circumvertical skin pattern has been applied to good effect, lifting the NAC and tightening the skin envelope to create a pleasing breast shape.

Surgical Technique – Staged Augmentation Mammaplasty

The MWL patient has damaged skin and parenchyma compared to a patient with a more proportionate body habitus. As a result, after the weight loss has occurred, the deflated breast is very prone to all manner of complications after the placement of an implant and tightening of the skin envelope. The severity of these complications seems to be directly proportionate to the amount of weight loss and the effect the weight loss has had on the breast. For this reason, many surgeons believe that staging the mastopexy with the augmentation is indicated to limit the incidence of complications and maximize the esthetic quality of the result. The advantages of this approach include being able to better judge how these two operations with differing goals can be effectively combined in the best way possible.

Typically, when the surgeries are staged, the mastopexy is performed first using the same periareolar or vertical approaches described earlier. This allows the surgeon to raise the NAC, reshape the breast, and reduce the breast skin envelope. Once the mastopexy is performed, the patient is allowed to heal and after a minimum of 6 months the surgeon can decide, now with fewer variables to deal with, which implant size and placement would provide the best esthetic result (Fig. 14.14A, B). The advantage of staging is that fewer variables are addressed at each procedure, thereby allowing greater accuracy with fewer complications. The disadvantage of the staged approach is that it is more costly, as two procedures are always planned as opposed to one in the combined approach. And in the case of needing to treat a complication, even a third procedure could well be required, all of which presents as a significant financial challenge for many patients. Additionally, when a combined approach does require revision, typically the revision is of a less demanding nature as opposed to a staged procedure where many of the same variables present challenges for each planned procedure.

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FIG. 14.14 (A) Preoperative appearance of a 45-year-old woman in preparation for completion of a staged augmentation mastopexy. She has previously undergone breast reduction followed by the loss of a significant amount of weight resulting in an underfilled and ptotic breast. (B) Final result.

Optimizing Outcomes

• Liberal use of the circumvertical pattern.

• Areolar control using the interlocking technique.

• Intraoperative use of tailor tacking to create the desired result.

• Conservative implant size.

• Simple implants (round versus anatomic).

Postoperative Care

Patients are placed in a well-fitted surgical bra immediately after the surgery and drains are used only rarely. With occlusive dressings in place patients may shower beginning on postoperative day 1 and are instructed to refrain from lifting anything over 4.5 kg (10 pounds) for 4 weeks. They are also instructed to refrain from vigorous exercise for 6 weeks. The initial dressings are changed at the 1 week postoperative visit and then routine incisional care is started.

Complications and Their Management

All of the commonly recognized potential complications of breast augmentation and mastopexy can occur when these two procedures are combined. These include infection, hematoma, seroma, hypertrophic scarring, delayed wound healing, and capsular contracture. Treatment of these complications mirrors what is commonly done for implant or mastopexy patients in general. However, there are two unique types of complications that tend to occur in MWL augmentation/mastopexy patients: implant malposition and recurrent ptosis.

Implant Malposition

Due to the loose nature of the skin envelope, postoperative loss of the position of the IMF or even lateral implant displacement can occur. In these cases, suture plication of the over dissected portion of the pocket can restore harmony between the position of the implant and the overlying breast. Such revisions are technically demanding but can greatly improve the quality of the result esthetically.

Recurrent Ptosis

Even despite attempts to overcorrect the degree of tightening of the breast, particularly along the vertical component, postoperative stretching of the skin with loss of an esthetic lower pole contour can occur. Here, the advantage of the combined procedure comes into play. Very often, simple retightening of the vertical component will provide very esthetic and permanent correction of this complication (Fig. 14.15A–E). When a staged procedure is performed, it can be difficult to assess the degree of tightening needed to create the desired shape. Therefore after the augmentation is performed at the second procedure, postoperative stretching of the skin envelope can then necessitate a third procedure to achieve the final desired result. A related complication relates to widening or shape distortion of the areola despite the use of the interlocking suture. Here, simple reapplication of the interlocking technique usually provides stable and long-term correction of the problem.

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FIG. 14.15 (A) Preoperative appearance of a 33-year-old woman in preparation for augmentation mastopexy after MWL. (B) Preoperative marks demonstrating the proposed circumvertical pattern. (C) 8 month postoperative result demonstrating a mild degree of recurrent ptosis. (D) Preoperative marks demonstrating a repeat circumvertical approach. (E) Final result showing appropriate lifting of the NAC and an overall esthetic shape.

Conclusion

Augmentation mastopexy is generally considered by esthetic breast surgeons to be one of the most challenging surgeries they perform. The level of complexity is compounded when this already difficult procedure is performed on the damaged, inelastic skin envelope that is seen in the MWL patient. Despite these obstacles, with proper preoperative planning and the appropriate application of sound surgical technique, excellent esthetic results can be obtained, with a tremendous degree of patient satisfaction.

References

1 Centers for Disease Control and Prevention, Department of Health and Human Services. Overweight and obesity: obesity trends: US overweight trends 1985-2009. http://www.cdc.gov/obesity/index.html, 2011. Accessed March 4

2 Maggard MA, Shugarman LR, Suttorp M, et al. Meta-analysis: surgical treatment of obesity. Ann Intern Med. 2005;142(7):547–559.

3 Torres JC, Oca CF, Garrison RN. Gastric bypass: Roux-en-Y gastrojejunostomy from the lesser curvature. South Med J. 1983;76(10):1217–1221.

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6 Scopinaro N, Gianetta E, Pandolfo N, et al. Bilio-pancreatic bypass. Proposal and preliminary experimental study of a new type of operation for the functional surgical treatment of obesity. Minerva Chir. 1976;31(10):560–566.

7 Sebastian JL. Bariatric surgery and work-up of the massive weight loss patient. Clin Plastic Surg. 2008;35(1):11–26.

8 Song AY, Jean RD, Hurwitz DJ, et al. A classification of contour deformities after bariatric weight loss: The Pittsburgh rating scale. Plast Reconstr Surg. 2005;116:1535.

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10 Sarwer DB, Wadden TA, Fabricatore AN. Psychosocial and behavioral aspects of bariatric surgery. Obes Res. 2005;13(4):639–648.

11 Boccieri LE, Meana M, Fisher BL. A review of psychosocial outcomes of surgery for morbid obesity. J Psychosom Res. 2002;52(3):155–165.

12 Herpetz S, Kielmann R, Wolf AM, et al. Does obesity surgery improve psychosocial functioning? A systematic review. Int J Obes Relat Metab Disord. 2003;27(11):1300–1314.

13 van Hout GC, van Oudheusden I, van Heck GL. Psychological profile of the morbidly obese. Obes Surg. 2002;14(5):479–488.

14 Losken A. Breast reshaping following massive weight loss: principles and techniques. Plast Reconstr Surg. 2010;126(3):1075–1085.

15 Rubin JP, Khaci G. Mastopexy after massive weight loss: dermal suspension and selective auto-augmentation. Clin Plast Surg. 2008;35:123–129.

16 Rubin JP. Mastopexy in the massive weight loss patient: dermal suspension and total parenchymal reshaping. Aesth Surg J. 2006;16:1622–1629.

17 Gusenoff JA, Rubin JP. Plastic surgery after weight loss: current concepts in massive weight loss surgery. Aesth Surg J. 2008;28(4):452–455.

18 Agha-Mohammadi S, Hurwitz DJ. Nutritional deficiency of post-bariatric surgery body contouring patients: what every plastic surgeon should know. Plast Reconstr Surg. 2008;122:604–613.

19 Alvarez-Leite JI. Nutrient deficiencies secondary to bariatric surgery. Curr Opin Clin Nutr Metab Care. 2004;7:569–575.

20 Madan AK, Orth WS, Tichansky DS, et al. Vitamin and trace mineral levels after laparoscopic gastric bypass. Obes Surg. 2006;16:603–606.

21 Hammond DC, Khuthaila DK, Kim J. The interlocking Gore-Tex suture for control of areolar diameter and shape. Plast Reconstr Surg. 2007;119:804.

22 Hammond DC, Hollender HA, Bouwense CL. The sit-up position in breast surgery. Plast Reconstr Surg. 2001;107(2):572–576.

23 Hammond DC, Alfonso D, Khuthaila DK. Mastopexy using the short scar periareolar inferior pedicle reduction technique. Plast Reconstr Surg. 2008;121(5):1533–1539.

24 Hammond DC. The short scar periareolar inferior pedicle reduction (SPAIR) mammaplasty. Semin Plast Surg. 2004;18(3):231–243.

25 Colen SR, Giese SY, Graf R, et al. Treatment of breast ptosis. Aesth Surg J. 2003;23(4):279–285.

26 Hammond DC. The SPAIR mammaplasty. Clin Plast Surg. 2002;29(3):411–421.

27 Hammond DC. Short scar periareolar inferior pedicle reduction (SPAIR) mammaplasty. Plast Reconstr Surg. 1999;103(3):890–901.

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