Introduction

Liposuction of the upper back is very important in body contouring surgery. Even considering that this region is loose skin, allowing free movement of the torso and arms, it shows good index of retraction after liposuction. We must inform patients in advance about this feature of the skin, so they do not feel that this is loose skin sagging caused by liposuction. The skin resection is limited to people with thinner skin and with excess skin hereditary characteristic. Especially after the age of 46, when the first signs of skin aging. Liposuction alone resolves the vast majority of cases.

Anatomical Aspects

The back and its extension towards the breast is a region of the body with its own characteristics in liposuction.

The thickness and the ratio between the lamellar and areal layers in the thin individual oscillate from 0.3 to 0.5 cm for the lamellar layer and 1.0 to 1.2 cm for the areolar layer, and may reach 0.5 to 0.8 cm for the lamellar layers and 1.5 to 2.2 cm for the areolar layer in obese individuals.

However, for morbid obesity these values may be higher, highlighting the increase in the lamellar layer.

In liposuction the dense connective tissue is very important because it is thicker in the upper back region, especially in the grooves formed by the excess skin that can result from both genetic inheritance (Fig. 15.1), obesity (Fig. 15.2A and D), sagging senile (Fig. 15.3A, B) or post liposuction (see Fig. 15.2 C and F).

FIG. 15.1 Constitutional skin flaccidity (genetics). The whole liposuction of the upper back was made through a minimal incision in the posterior axilla (arrow). Pre- and postoperative views.

FIG. 15.2 Good skin retraction (A, B, D, E) shown. Thin and senile skin (C and F) may present residual skin protuberance.

FIG. 15.3 Resection of senile skin flaccidity.

Another important feature is the loose connective tissue (Fig. 15.4B) that grips the skin and subcutaneous muscle (aponeurosis) in this region making it easier to rip of the whole skin and subcutaneous tissue without detaching it surgically during resection flaps (Fig. 15.4C and D).

FIG. 15.4 (A) Liposuction before skin resection. (B) Skin resection. (C) Excised skin. (D) Suture made (posterior view).

Surgical Treatment

Planning – Demarcation

Liposuction of the upper back can be performed only by minimal incisions of 5 mm at each subsequent level of the armpits (see Fig. 15.1A and C).

Where it is planned, resection of skin incisions may be made in the flaps (see Fig. 15.4).

The upper line of resection of the back is marked by pulling down the skin of this region and marking ± 2 cm above the submammary horizontal extension of the line (Fig. 15.5E and 15.8F).

FIG. 15.5 Constitutional skin excess exacerbated by obesity (A–F). The sequence shows the demarcation of the back skin resection and associated mammaplasty.

FIG. 15.8 Pre- and postoperative views (A and D, B and E, C and F). The whole skin flaccidity of the back was treated by the incision in the back. The abdomen was treated with posterior surgical approach and the hips only with liposuction.

The score line is bound low by the amount of skin which is desirable to withdraw (see Fig. 15.5C and E).

It is important to clarify to the patient the possible fall of the scar and the consequent need for additional corrections that are usually made 3 months after liposuction.

Surgical Technique

Liposuction is initiated from the deepest layer (lamellar) (see Fig. 15.4A) to the most superficial layer (areolar). It should be aspirated maximally from the lamellar layer, because its larger and turgid cells are still softened by wetting solution infiltration. It will result in a thicker layer of fibrous connective tissue (see Fig. 15.4B), allowing a better grip of this flap and lower recurrence of sagging. The aspiration of the areolar layer is also significant, as it is important for the surgeon to leave the thickness of the tissues according to his preference.

In cases where the skin resection is programmed, liposuction under the flap should be total. Thus, the resection is reduced only to the skin layer, leaving the vascularization and innervation intact. This avoids areas of paresthesia and discomfort, which are sources of complaint from patients (see Fig. 15.4B and C).

Initially, our incisions, whenever possible, extend to the end of the spine area, but we leave markings that allow us to connect the incisions if necessary (see Figs 15.5F, 15.4D and 15.5E).

When indicated, these incisions can be extended to the anterior thorax with reverse resection of the upper abdomen (reverse abdominoplasty) or surgical correction of the breast (Figs 15.6 and 15.7).

FIG. 15.6 (A and B) Skin resection up to the lateral border of the breast (anterior view). (C and D) After suture, the surgical approach to the breasts starts in dorsal decubitus.

FIG. 15.7 The sequence shows the detachment (A), the nipple–areola complex delimitation (B), the skin resection (C and D) and the mounting of the breast (E and F).

Postoperative Care and Results

At the first examination, it is possible to assess with certainty the thickness of the skin, fat tissue to be aspirated, sagging, and pre-existing skin excess.

The advantage of skin resection and its applicability is questioned by the occasional widening of scars in patients with thin skin and hypertrophy scars in patients with thicker skin (see Figs 15.3B and 15.10), not excluding the fact that patients with thicker skin may also present scar enlargement.

We limit physical fitness activities for 3 months. This would not impair an early return to work.

The use of body shaping garments provides comfort for the patient and helps stabilize the skin in its position.

Complications

Some ecchymosis is common. Hematomas are rare, but should be avoided, especially in liposuction accompanied by skin resection.

Often liposuction of the back (see Fig. 15.1A and C) is accompanied by liposuction of the hips and sacral region, leaving these regions exposed to occasional fluid collections (seroma).

Treatment may require the application of a suction drain for 3–4 days when the aspirated fluid collection volume is above 40 ml.

The risk of skin necrosis is avoided by supporting the operated area with a soft surface and evenly distributing the weight over the entire surface of the patient (see Fig. 15.4A and D).

Precise skin wound closures will prevent unsightly scars.

Conclusion

Reviewing 902 cases of upper back liposuction, there were 23 cases (2.55%) of skin resection concurrent with liposuction of the back (see Fig. 15.2). This argues for very conservative practice, with skin resection reserved for cases of severe pre-existing sagging (Fig. 15.8B–E and C–F), and especially in patients undergoing major weight loss where the skin has already suffered its maximum retraction.

Skin resection of the back has almost a formal indication in these cases and when properly indicated and performed brings great benefits for the patient (Figs 15.9–15.11).

FIG. 15.9 The scar position is determined by the bra rolls (A and B). The dotted line (F) shows the final scar position.

FIG. 15.10 Pre- and postoperative views (A and D, B and E, C and F).

FIG. 15.11 Not rare, but patients use tattoos to hide scars, even if they are small.

When in doubt, perform liposuction and a subsequent surgical resection (i.e., bra line lipectomy) after 3 months or later.