Breast reshaping using autologous tissues after massive weight loss

Published on 23/05/2015 by admin

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Chapter 10 Breast reshaping using autologous tissues after massive weight loss

Moustapha Hamdi, Serhan Tuncer

Key Points

• Breast shape in patients after massive weight loss (MWL) often appears as a “pancake” deformity.

• Conventional techniques of mammaplasty usually fail to correct breast shape in this specific group of patients.

• Breast volume deficiency is better addressed using autologous tissue whenever available.

• “Spare-parts” and “recycled tissue” concepts are the fundamental basis of the surgical technique.

• Redundant tissue over the axillary region, back, abdomen, or thigh usually provides adequate tissue for flap transfer, which can be used for autologous breast augmentation.

Introduction

Breast deformities are the most challenging and variable part of the massive weight loss (MWL) patient; thus a thorough definition of the problem and an accordingly chosen technique determine the success of the surgical outcome.¹^–⁵ Breast deformities of the MWL patient differ from typically enlarged or ptotic breasts and therefore well-known techniques usually fail in this group. Significant breast volume depletion, and loss of upper pole and medial fullness resulting in the formation of flattened parenchyma against the chest wall, known as the “pancake” appearance, are the most common changes.^4,⁵ The majority of patients present with grade III ptosis and the two breasts are usually asymmetric because of disproportional volume loss. The breasts are displaced laterally in continuity with the lateral chest rolls and the nipple–areola complex is displaced medially. The skin envelope shows significant laxity and is covered by stretch marks.

The patients can present with excessive, sufficient, or insufficient breast volume.¹ Although MWL patients rarely have enlarged breasts, the deformity is treated by one of the reduction techniques. However, instead of standard reduction techniques, ligamentous system preservation combined with retightening procedures provides more satisfactory and long-lasting results. Therefore, we prefer a Würinger’s septum-based reduction technique.⁶ The second group includes patients who have droopy breasts with sufficient volume. Existing dermoglandular tissues are usually adequate to form a natural-looking breast and most of the patients benefit from one of the mastopexy techniques. Lastly, the majority of patients have saggy breasts with insufficient volume, so providing extra volume is mandatory to establish naturally projecting breasts. One option to correct this type of deformity is to combine mastopexy techniques with implant augmentation.^1,⁷ However, there are certain challenges with implant augmentation–mastopexy in MWL patients. Due to excessive skin laxity and loss of dermoglandular suspension, an unnatural appearance and recurrent ptosis are the most common problems after implant augmentation.⁷

On the other hand, most of these patients present with skin-fat excess, which requires excision and skin tightening procedures. This redundant skin excess provides excellent material for breast autoaugmentation.

Clinical Approach

MWL patients have other redundant parts on their body that deserve to be removed to achieve a satisfactory result. However, instead of discarding these parts, they can be used for autoaugmentation. Parts of the body that can be used to augment the breast are divided into two main groups. The first group includes the redundant skin and subcutaneous tissue near the breast that can be transferred on a reliable vascular base and the second group includes distant parts that can only be transferred as free flaps.

Techniques Based on Locoregional Tissue

In most MWL patients, breast deformity is accompanied by lateral skin redundancy or “side rolls” in the lateral thoracic area. This axillary extension of the breast can be used to provide autoaugmentation in patients with insufficient breast volume, using different surgical techniques.¹^–⁵ ^,8 ^,10 Rubin described a total parenchymal breast reshaping with dermal suspension mastopexy using the excess tissues around the breast mound.^2,⁵ A modified Wise pattern with lateral extension to encompass any significant lateral rolls was used. The technique was based on de-epithelialization of the entire region, then lateral and medial dermoglandular flaps were elevated securing them together with the central pedicle to the second or third rib periosteum with permanent sutures. Hurwitz et al described the use of lateral side rolls as a spiral flap to augment and reshape the breast in MWL patients.⁸ In this technique they de-epithelialized fasciocutaneous flap extensions of the Wise pattern mastopexy.

We suggested the use of lateral redundant dermoglandular tissue based on lateral intercostal artery perforators (LICAP) with some personal modifications.³ The technique evolved from our initial experience with the LICAP flap for partial breast reconstruction within a clinical algorithm based on the location of the defect and the availability of these perforators.⁹ A case report of pedicled perforator flaps for breast augmentation was subsequently published.¹⁰ We also reported our clinical experience with ICAP flaps and addressed the use of pedicled LICAP flaps in MWL patients.³ In a recent study we described the anatomical details of the perforators and the flap design.¹¹ As the side rolls extend more posteriorly to the back of the patient, perforators based on the thoracodorsal system can also be used as the main pedicle of the redundant tissue. The thoracodorsal artery perforator (TDAP) flap is another valuable tool that can be used for reshaping the breast via the autoaugmentation principle.^10,¹²

Techniques Based on Distant Tissue

Other parts of the body that need to be addressed during body contouring of the MWL patient are the abdomen, thighs, and buttocks. Contouring of all three parts is well described, with several modifications. The main concept in body reshaping is based on removal of these excess tissues. However, these skin and subcutaneous tissues can be transferred as free flaps and used for augmenting the breast in a single session. Although usage of these tissues is popular and widely used in postmastectomy breast reconstruction, there is little experience of augmenting the breast with free flaps for cosmetic purposes. The whole abdomen can be raised as two individual deep inferior epigastric perforator (DIEAP) or muscle sparing TRAM flaps to be transferred to the breast. Also, during the inner thigh lifting procedure, transverse skin islands can be prepared as gracilis musculocutaneous flaps and used for bilateral breast augmentation. Schoeller et al proposed a medial thigh lift free flap for autologous breast augmentation and presented their experience with three MWL patients.¹³ Likewise, upper gluteal excess and saggy infragluteal parts can be prepared on superior gluteal or inferior gluteal artery perforator flaps, respectively, to be used for breast augmentation of the MWL patient.

Preoperative Preparation

After routine preoperative screening tests and assessment of risk factors, the most important step during the preoperative period is to decide which excess part of the body will be used for autoaugmentation. If the patient has significant side rolls and the preoperative evaluation demonstrates that this excess tissue can provide sufficient volume for the breast, then we prefer to perform a pedicled flap on the lateral intercostal or, occasionally, thoracodorsal perforators. Due to relatively higher rates of complications in MWL patients, volume enhancement with free flaps is less preferred. When there is no lateral skin excess, bilateral abdominal free flaps either on paraumbilical perforators or as a muscle-sparing TRAM flap to be transferred to the breast, can be considered in patients carefully selected for breast augmentation. On the other hand, patients who want to get rid of redundant skin in the thigh region and also need to have an augmentation of their deflated breasts can be good candidates for free transverse musculocutaneous gracilis flap (TMG) transfer.

Mapping of the vascular anatomy of the chosen flap before the operation makes the surgery easier and shortens the operative time.¹⁴ Combining two procedures and an additional free flap transfer lengthens the operative time; hence any method used to facilitate the surgery is invaluable. Usually, perforators of the LICAP flap or TDAP flap are located with a unidirectional hand-held Doppler. Following the previously described anatomical outlines, it is relatively straightforward to find a reliable perforator on the back. However, the surface area of the abdomen is wide and the number and location of the paraumbilical perforators show great variability. Therefore more objective and reliable methods are needed for perforator mapping. Multidetector computed tomographic (MDCT) angiography and magnetic resonance angiography are extremely helpful tools to navigate the major perforators to be selected. Both techniques provide the exact coordinates of the points where the major perforator pierces the fascia referring to the umblicus.^15,¹⁶

Surgical Technique

LICAP Flap (Fig. 10.1)

The largest or “dominant” perforators are found between the 5th and 7th intercostal spaces in 84% of cases. The mean distance of these dominant perforators from the anterior border of the latissimus dorsi (LD) muscle varies between 2.77 and 3.68 cm.¹¹ The flap is designed lateral to the breast over the axilla and lateral thoracic area. The anterior border of the flap should include the junction of the inframammary fold (IMF) with the anterior axillary line to allow primary donor site closure. The width of the flap depends on skin redundancy and varies between 8 and 15 cm. The perforators are located with a Doppler and the closest and the most anterior perforator to the breast is chosen for adequate arc of rotation of the flap. The LD muscle is exposed after incision and the flap is elevated above the muscle fascia. Once the largest perforator closer to the pectoralis major muscle is found, it is freed off the surrounding tissue. The serratus anterior muscle is split and the perforator is dissected up to its exit above the rib. If a longer pedicle is required, dissection of the main pedicle can proceed within the costal groove. Once dissection of the perforator is complete, the rest of the flap is elevated easily above the muscle fascia. The inferior incision of the flap is then extended into the IMF. The breast gland is dissected and a retroglandular pocket is prepared for the flap. The mastopexy is first marked in a vertical scar mammaplasty pattern. The horizontal extent of the reduction pattern is determined during surgery, after harvesting and insetting the flap.

FIG. 10.1 A 41-year-old patient after 65 kg weight loss.

The patient was a candidate for breast pexy/augmentation. The side rolls, which were used for breast augmentation, were elevated pedicled flaps based on the lateral intercostal perforators. The flaps were placed into the retromammary space bilaterally. A skin mammaplasty was then performed. (A–C) Preoperative views; (D) the LICAP flap was marked over the side rolls; (E) the flap was dissected and completely islanded; (F) after placing the flap behind the gland, the mastopexy was done using an L-scar mammaplasty; (G–I) postoperative views; (J) a lateral view of the breast with the donor site of the augmentation flap (the excised side roll).

DIEAP Flap (Fig. 10.2)

The abdomen is considered the ideal donor site for autologous breast reconstruction after mastectomy. The morbidity associated with abdominal wall complications has limited the use of the TRAM flap and a search to minimize these complications led to the rise of the DIEAP flap.^17,¹⁸ In the majority of the MWL patients an abdominoplasty procedure is needed. In carefully selected patients, the whole abdominal tissue can be raised on DIEAP flaps on each side of the abdomen to be transferred to the breast as a free flap. Preoperative mapping of the perforator anatomy with MDCT facilitates identification of the dominant perforator and the intramuscular course of the vessels.¹⁵ Abdominal scars from previous surgeries should also be considered before the operation. In general, most MWL patients present with different types of abdominal scars from bariatric surgery. The majority of these scars are midline scars and during two hemi-flap transfers they have no negative impact on flap circulation. Because the traditional belt lipectomy procedure is less effective in most of the MWL patients, a fleur-de-lis pattern excision, to achieve greater improvement above the umbilicus, and resulting in an extra midline scar, is safely performed by some surgeons.^19,²⁰ On the other hand, a retrospective study by Parrett et al demonstrated that donor site morbidities, including wound breakdown, abdominal laxity and bulging, were significantly higher compared to DIEAP flap patients with no previous scars.²¹

FIG. 10.2 A 31-year-old female who had lost a total of 35 kg following bariatric surgery with gastric band insertion and requested an abdominoplasty and mastopexy/augmentation for the contralateral breast.

A vertical scar mastopexy was performed together with bilateral breast augmentation using DIEAP free flaps. (A, B) The preoperative views with surgical markings. The bilateral DIEAP flaps were incorporated within the abdominoplasty marking. (C, D) The preoperative MDCT images showed the dominant perforator on both sides. (E) Bilateral DIEAP flaps were based on the preoperative marked perforators. (F) The DIEAP flap was anastomosed to the internal mammary vessels through the mastopexy incision. (G, H) The outcome at 1 year postoperatively.

The procedure can be performed by two teams to shorten the operative time. One team begins by preparing the breast for reshaping and exposes the internal mammary vessels for the anastomosis. The other team elevates the two DIEAP flaps based on the previously identified paraumbilical perforators, following meticulous microsurgical dissection principles. Once the flaps and the recipient sites are ready each flap is transferred to the contralateral breast for autoaugmentation. First, the anastomoses are completed and then the flap skin is de-epithelialized, leaving a small vertical area at the lower pole intact for postoperative monitoring. The flap dermis is tacked into the pectoralis major fascia. The flap can be folded or gathered inferiorly to obtain better breast projection or cone. Breast reshaping with mastopexy and autoaugmentation using DIEAP flap is finalized by skin closure. It is usually difficult to estimate the amount of skin to be excised from the breast during mastopexy and this should be performed after flap insetting in order to facilitate tension-free closure over the DIEAP flap. This complex procedure is long, and prone to the well-known complications of a long free flap procedure, but it provides an effective and satisfactory result in patients who need both breast and abdominal reshaping together and do not have sufficient volume at the breasts and lateral side rolls for autoaugmentation.

TMG Flap

The use of a TMG free flap for the reconstruction of various anatomical regions was described a long time ago, and Yousif et al demonstrated that this flap could be raised safely when the skin paddle is designed in a transverse fashion.²² Historically, the tissue of the upper medial thigh has received very little attention for the purpose of reconstructing an esthetically pleasing breast mound. During the last few years the use of free TMG flaps for breast reconstruction has been popularized, especially for women who have inadequate abdominal bulk or who had previous abdominal surgery.^23,²⁴

Excessive skin and soft tissue on the medial thigh after MWL is a common problem among this patient group and an appropriate lifting procedure is almost always needed.²⁵ Schoeller et al reported medial thigh lifting combined with the use of excised tissues as bilateral free gracilis musculocutaneous flaps for breast augmentation in a single-stage procedure.¹³

Preoperatively, the skin paddle and the gracilis muscle are marked with the patient in standing position. Occasionally it can be difficult to locate the muscle in an obese or a MWL patient. The adductor magnus muscle is usually palpated more easily and the gracilis lies just posterior to this muscle. The upper incision is placed 1–2 cm inferior to the groin fold in order to prevent distortion of the external genitalia. The medial margin is located 5 cm ventral to the adductor muscle and should not be above the great saphenous vein. The posterior margin is extended to the midgluteal line and the main volume is achieved from this part of the flap. The skin paddle is crescent-shaped and the width of the flap is determined according to the amount of skin laxity that allows primary closure; this can be predicted with a simple pinch test.

The operation is performed with the patient in the supine position with the hips abducted and the knee flexed. One team prepares the donor site and the recipient vessels, and the other team harvests the flap. The flap is elevated in an anterior to posterior fashion. Once the great saphenous vein is spared and the adductor fascia is incised, dissection proceeds between the avascular septum between the gracilis and adductor muscles bluntly. The proximal vascular pedicle is easily found and dissected to the profunda femoris vessels to gain a 6–8 cm long pedicle. Next, the flap is raised from the posterior margin until the posterior border of the gracilis muscle is reached. Then the gracilis muscle is separated from adductor longus and adductor magnus muscles and dissected distally through the inferior incision with the help of fingers until its tendinous junction is reached. Finally, muscle tendon is divided through the subcutaneous tunnel with the help of long scissors, without the need for a second incision at the knee level. The pedicle is divided and the flap is transferred to the subcutaneous pocket on the chest wall. Usually an inverted-T skin excision followed by autoaugmentation is performed to achieve a pleasing shape. After the vascular anastomosis to the internal mammary vessels is finished, the flap is shaped inside the breast pocket. Shaping of the TMG flap is different from other free flaps. Both ends of the skin paddle are brought together and sutured in order to create a breast cone and give the flap extra projection. The skin paddle is de-epithelialized and buried in the subcutaneous pocket; however, a small elliptic skin island is preserved and located either in the vertical or in the horizontal scar as a monitor to be removed later. In order to prevent excessive excision, skin removal from the ptotic breast is done at the end of the procedure.

Postoperative Care

Postoperative care can sometimes pose a challenge for this group as MWL patients usually have multiple accompanying comorbidities along with an increased risk for general postoperative complications.^26,²⁷ Especially in cases where multiple procedures have been carried out, patients should be observed under ICU conditions in the early postoperative phase (24 hours) or in a so-called semi-ICU where patients can stay overnight, mainly for free flap monitoring. Careful monitoring of vital signs, along with urinary output, is critical and fluid replacement must be administered accordingly. A control total blood count and biochemistry panel should be obtained to determine any critical blood loss or biochemical imbalances and the necessary measures must be taken according to the results.

Precautions must also be taken to avoid the risk of thromboembolus, especially in the first hours after surgery when the patient is immobilized.²⁶ The use of compression socks or compression devices is advised for all patients. Pneumatic compression systems for the lower extremity are quite useful devices and serve well for the purpose. Patients may also be given low molecular weight heparin during the immobilized period. It is extremely important to mobilize patients as early as possible to avoid any complications related to prolonged immobilization.

Free and pedicled flaps are followed up according to usual protocol but the follow up of free flaps that are placed in a tissue pocket can pose a challenge, resulting in difficulty detecting early critical changes in color, temperature and capillary fill. For this reason, it is important to transfer free flaps with a skin island that allows monitoring. Changes in color, temperature and capillary fill can be observed via this skin island, which can be removed under local anesthesia after the healing phase is complete.

Complications and Their Management

MWL patients are susceptible to various complications after body contouring procedures. In a previous study of 449 post-bariatric surgery patients, 42% of the subjects developed complications and the rates ranged from 8 to 66% in different series.²⁸^–³⁰ Complications in the postoperative period include wound healing problems, seromas, thromboembolic complications, infection, hematoma, and necrosis.²⁸^–³¹ Patients’ body mass index, overall medical condition and comorbid factors play an important role in developing postoperative problems. Both seroma formation and wound healing problems are seen in the abdominal and thigh regions and the incidence of such complications is lower in the breast area.^28,²⁹ The most important risk factor for seroma was found to be the weight of skin excised at the time of surgery.²⁹ In the thigh region, keeping the anterior border of the excision posterior to the femoral triangle is very important in order to prevent seroma, lymphatic collection and lymphedema. Another important determinant for postoperative complications is combining procedures or more aggressively applying total body lifting procedures.³² Additional application of two free flap transfers for breast autoaugmentation further lengthens the operative time and might increase the overall complication rates. However, there are no data regarding the complication rates after free flap transfer in MWL patients. On the other hand, perfusion complications can be expected at the flaps. Previous clinical data demonstrate that, as the body mass index gets higher, the incidence of venous congestion and fat necrosis increases.³³^–³⁵ Fat necrosis or partial flap necrosis necessitates debridement, and if a significant amount of flap loss occurs, volume replacement can be achieved by fat grafting. In case of total flap loss the situation can be catastrophic both for the patient and the surgeon and the flap should be replaced by a silicone implant. Preoperative determination of the risk factors, careful patient selection for combining procedures, and appropriate postoperative care are the key steps to be followed for minimizing major and minor complications.