Summary/Key Points

Patient Selection

Breast deformities after massive weight loss vary significantly. Common findings include breast ptosis, medialization of the nipple–areola complex, and extension to a lateral chest roll. Many procedures exist to treat the deflated breast after massive weight loss, including short scar mastopexy techniques and combined augmentation/mastopexy.^1–7 However, achieving long-lasting results with these techniques in the setting of severe skin laxity can be challenging. The goals for mastopexy after massive weight loss include obtaining a youthful, well-contoured breast with upper pole fullness, proper nipple positioning, and a long-lasting aesthetic result.

Patient goals and expectations must be properly assessed before proceeding with surgery. A full history and physical is always performed, with an emphasis on history of breast disease and analysis of the deformities. Optimal patient criteria for the dermal suspension, parenchymal reshaping mastopexy include profound parenchymal volume loss, skin envelope redundancy, Grade 3 nipple ptosis, medialization of the nipple–areola complex, and the presence of a lateral skin/fat roll or lateral chest wall laxity.⁸

Indications

As noted above, the indications for dermal suspension, parenchymal reshaping with selective auto-augmentation include patients with deflated, flattened breasts. Patients tend to have dramatic skin laxity and skin excess. Additionally, many patients present with lateral chest rolls of excess skin and/or fat,⁹ a nd this procedure is very effective in treating that deformity. The goals of this operation include using all available breast tissue and recruitment of surrounding chest wall tissue for selective auto-augmentation, proper placement of the nipple, restoring upper pole fullness, reshaping and reducing the skin envelope without relying on it for support, and eliminating the lateral chest roll and restoring the lateral sweep of the breast.

Relatively few contraindications exist for this procedure. Patients who are active smokers or users of tobacco products are asked to stop one month prior to and after surgery. In accordance with the American Cancer Society, all patients are screened for breast cancer with mammography as appropriate given their individual histories.¹⁰ Patients who have had prior breast surgery may not be candidates for this procedure if the scars interfere with the planned procedure. Similarly, patients with severe fibrocystic disease or active intertrigo may not be ideal for surgery. Patients desiring a marked increase in breast volume may be better served by an augmentation/mastopexy technique.

Operative Technique

Markings for the dermal suspension, parenchymal reshaping mastopexy are based on an extended Wise pattern with the nipple–areola complex based on a central and inferior pedicle. The sternal notch is identified and marked. A point on the clavicle 5 cm lateral to the sternal notch is identified and a line is drawn down the breast meridian. Often the nipple–areola complex in the massive weight loss patient will lie medial to this mark. The nipple position is then assessed by palpating the inframammary fold and projecting this point onto the surface of the breast. The top of the keyhole Wise pattern is planned from 2 cm above this point. Five centimeter vertical limbs are measured from the keyhole pattern. The Wise pattern is then completed with extension of the lateral portion to encompass the lateral skin roll. This will aid in removal of the skin roll and use of this de-epithelialized portion for selective auto-augmentation. The de-epithelialized portion is limited to the posterior axillary line and robust perforators from the lateral thoracic region allow the flap to be mobilized. The nipple–areola complex is measured at 42 mm with a cookie cutter or washer and de-epithelialization of the entire Wise pattern is begun (Fig. 41.1A).

Fig. 41.1 A–G Diagramatic representation of the markings and operative sequence.

A Markings, demonstrating extended Wise pattern and correction of medialized nipple position; B Exposure of breast parenchyma and elevation of medial and lateral flaps; C Placement of ‘key’ suture suspending central dermal extension to rib periosteum; D Suspension of medial and lateral flaps, along with the design of the plication; E Completing the plication with shortening of the nipple to inframammary fold distance; F defining the lateral curve of the breast; and G release of periareolar dermis.

A pedicle base of 10 cm is measured approximately 6–7 cm from the medial aspect of the Wise pattern. All portions of the incision are then scored through dermis except at its base and the breast parenchyma is then raised as skin flaps with a thickness of 1 to 1.5 cm (Fig. 41.1B). The flaps are constantly assessed by feel to make sure they are of uniform thickness. The flaps are raised until pectoralis fascia is reached and then elevation continues up to the level of the clavicle. Skin flap attachments to the chest wall medially and laterally are released to allow for the dermal suspension and parenchymal reshaping with appropriate redraping of the overlying tissue flaps. Care is taken not to release attachments in the midline over the sternum, which could result in synmastia. Medial and lateral parenchymal flaps are then raised (the flaps usually discarded in a Wise pattern breast reduction) maintaining their attachments to the central pedicle and preserving the 10 cm pedicle base with no undermining.

The first step in the dermal suspension is to secure the top of the de-epithelialized key-hole dermis to the level of the second rib along the breast meridian (Fig. 41.1C). If the central dermal extension is short from the nipple, then the pedicle may need to be secured at a lower rib level to prevent excessive nipple elevation. Fingers of the non-dominant hand are placed in the intercostal spaces surrounding the rib, making sure that the zero-braided nylon suture is safely hitting rib periosteum. Sutures are buried in a mattress fashion. Two sutures are usually placed to ensure stability at this first point of fixation and at the point of fixation for both lateral and medial flaps. Next, the lateral breast flap is secured to the chest wall with periosteal sutures. The first suture is usually placed at one rib level below where the previous central pedicle was suspended (i.e. the third rib). This suture is placed as medially as possible, usually directly under the central pedicle. This is secured with two mattress sutures as well for reinforcement. The length of this flap can be reduced to selectively reduce the amount of auto-augmentation desired. The medial flap is then rotated up to approximately the fourth rib and sutured with periosteal sutures. Redraping of the skin flaps periodically help to assess whether accurate levels of dermal suspension have been achieved.

Parenchymal reshaping is performed using 2-0 absorbable polyglactin suture. The lateral flap is approximated to the central dermal extension (Fig. 41.1D) first using interrupted sutures and then overlayed with a running suture. The same process is repeated medially. To increase nipple projection and shorten the distance from the nipple to the inframammary fold, an inferior plication is created to set a distance of 5 cm (Fig. 41.1E).

Symmetry is essential in performing this procedure and if possible suspension and plication should be performed simultaneously. Suspension and plication is performed with the patient in a sitting position and arms secured on arm boards. The plication pattern and extent of plication necessary varies by patient and requires intra-operative decision making that cannot be predetermined. Additional rows of plication sutures may be needed to achieve an optimal result.

To shape the lateral curvature of the breast, the lateral breast flap is secured to the chest wall fascia (Fig. 41.1F), and not to rib periosteum, to avoid injury to the lateral thoracic nerves and vessels. Securing this side of the flap prevents lateral bulging and further enhances nipple projection. Final projection and shape is assessed continuously by redraping the skin flaps to assess contour. The skin flaps are first approximated with a 2-0 polypropylene suture over a petroleum-gauze bolster to protect the skin and secure the T-point during the first postoperative week. Staples are then used to approximate the rest of the skin closure. Skin closure is then performed with two-layer absorbable suture in the deep and superficial dermis. A drain is placed laterally. Sometimes the nipple will be tethered in a lateral, medial, or inferior position and will need to be released to fit into the keyhole pattern. The nipple–areola complex is retracted with a double hook and an Army-Navy retractor holds the skin in the keyhole back to allow release of the tethered dermis with cautery (Fig. 41.1G). The dermis can be safely scored halfway around the circumference of the areola, due to the robust blood supply of the central pedicle.

Representative cases are shown in Figs 41.2–41.5.

Fig. 41.2 A 57-year-old woman after 60 kg (130 lb) weight loss.

A–C Preoperative views, D–F markings, G–H intraoperative views demonstrate the shaped breast. I–K Postoperative results at 1 month, L–N 1 year and O–Q 2 years.

Reprinted with permission from: Rubin JP, Gusenoff JA, Coon D. Dermal suspension and parenchymal reshaping mastopexy after massive weight loss. Statistical analysis with concomitant procedures from a prospective registry. Plast Reconstr Surg 2009, 123(3):782–789.

Fig. 41.3 A–C 48-year-old woman after 63 kg (140 lb) weight loss. This patient had an abdominoplasty with vertical resection performed prior to the mastopexy. Postoperative results shown at D–F 6 months and G–I 13 months.

Fig. 41.4 A–C A 34-year-old woman after 61 kg (135 lb) weight loss and a large amount of breast volume. D–F Preoperative markings. G–I Postoperative results shown at 4 months.

Fig. 41.5 A–C A 44-year-old woman after 52 kg (115 lb) weight loss and only moderate breast volume. This patient had an abdominoplasty with vertical resection performed at the same time as the mastopexy. D–F Postoperative results shown at 18 months.

Complications

Over 100 cases have been performed by the senior author (J.P.R.), and complications have included seroma (<5%), wound dehiscence at the T-point (<5%), hematoma (1%), and minor skin necrosis (<5%). No cases of nipple loss or major wound complications have occurred.

Pitfalls and How to Correct

The disadvantages of the dermal suspension, parenchymal suspension mastopexy with selective auto-augmentation include lengthy scars, extensive de-epithelialization, and a significant amount of intraoperative decision making regarding the dermal plication that cannot be premarked. Despite these disadvantages, this technique has been safe and reliable, with relatively few complications. The most common complications seen with this procedure include seroma formation (<3%), occasionally when a large amount of fat is excised from the lateral chest wall, and wound dehiscence from breasts that may be closed under high tension (<3%).

One potential pitfall of this procedure is failure to recognize lowering of the inframammary fold when combining the mastopexy with an abdominoplasty. Care should be taken to reassess the fold once the abdomen has been tightened. Similarly, when a fleur-de-lis abdominoplasty is performed, tension on tissues will rotate the fold medially. Correction of the markings intraoperatively may include raising the estimated line of inferior de-epithelialization prior to performing the mastopexy and also lowering the nipple position slightly.

When combined with a fleur-de-lis abdominoplasty, a bunching of tissues may result between the breasts. This dog ear should be addressed in a delayed fashion after swelling subsides. A small revision to the superior portion of the fleur-de-lis abdominoplasty can be addressed in 6–12 months if still prominent.

A second pitfall is failure to maintain a constant thickness of 1 to 1.5 cm on the skin flaps to prevent skin flap necrosis. If the flaps are made too thin near the T-point, blood supply can be compromised and delayed wound healing can occur. Any delayed healing at the T-point should be managed with local wound care. Revisions can be performed if wound healing is delayed.

A third pitfall to this procedure is insufficient dermal plication intraoperatively. Failure to obtain an optimal shape intraoperatively can result in suboptimal breast shape over time. If plication results in poor shape when the skin is redraped, the plication sutures should be removed and replaced in a different pattern. At first, the breasts will appear very high and projected, sometimes with an appearance of synmastia. Over time, tissues will relax and the breasts will achieve a more natural appearance and the appearance of synmastia will resolve since the sternal attachments were not disrupted.

Postoperative Care

A light compressive dressing with an elastic wrap is used for the first 5 days. Patients are then seen in the office and the dressing is removed. The surgeon is present for removal of the dressing to provide reassurance and limit patient distress. Drains are removed at the first post-operative visit or when producing less than 30 ml per drain per day. Bolster stitches at the inferior T-point are also removed at the first postoperative visit. Patients are placed in a sports bra for 6 weeks to allow the incisions to heal prior to the use of an underwired bra. Patients having the dermal suspension, parenchymal reshaping procedure performed alone often go home the same day; however, if combined with other procedures patients usually stay in the hospital overnight. Heavy lifting and strenuous exercise are limited for the first 4–6 weeks after surgery.