Introduction

After massive weight loss patients often present varying skin and tissue redundancy in the different body regions. Besides the typical lower body deformities, tissue redundancy is frequently present in the area of the upper arm, the lateral and dorsal thorax, as well as characteristic deformities of the breast, including a significant volume loss in combination with skin redundancy and extreme nipple–areola complex ptosis and medialization.

In the past, reconstructive operations such as breast reshaping, arm- and back-lifts were performed as single-stage procedures, especially for patients after massive weight loss. As part of a progression in this specific subfield of plastic surgery, modern treatment concepts have been established, such as the upper body lift, with or without a circumferential upper thoracic lift.^1–7 Besides the reconstruction of the breast with implants or alternatively with autologous tissues from the upper abdomen and/or lateral thorax, these regions can be sufficiently tightened in a single procedure, positioning the scar as a continuation of the submammary fold, ascending to the axillary crease. Patients with mild to moderate skin and tissue excess in the dorsal thoracic region can benefit from a sufficient skin tightening in this area by this approach. The upper arm reconstruction can easily be continued, without any interaction with the axillary reconstruction. In individual cases with severe skin excess at the dorsal thorax, a direct approach in terms of a bra-line lift can be performed⁴ (Fig. 17.1).

FIG. 17.1 Markings of the bra-line backlift include the upper and lower incision line (red line), which should result in the estimated scar line (dotted line) by means of a pinch test.

Due to the poor skin quality with its consequently reduced retraction capabilities in this patient subgroup, liposuction techniques have not been able to provide an alternative treatment option. However, its indispensability as an adjunct procedure has to be emphasized.

The upper body lift is a combined approach for the breasts and arms and eliminating skin excess in the axillary and back regions in a single-stage operation. It further allows the autoaugmentation of volume deficient breasts in female patients by tissue transfer from the lateral thoracic and upper abdominal regions.

Preoperative Preparation

For general information please refer to Chapter 38.

The decision for an upper body lift is made on the extent of skin and soft tissue excess at the lateral and dorsal thoracic wall. The classification of the lateral folds after massive weight loss is designated by Strauch et al into an upper breast roll, followed by a lower scapular roll or a deeper lower chest/thoracic roll. An analogous classification is made for the iliac area as hip rolls. The folds can be seen individually, often with a fluent passage.⁸ The two upper folds often can be treated by various surgical options and are only peripherally influenced by the lower body lift alone, whereas the two lower folds can only effectively be treated by a lower body lift or a belt lipectomy (Fig. 17.2).

FIG. 17.2 Schematic demonstration of abdominal, lateral and back rolls.

Operative planning in patients with multiple trunk rolls has to include additional approaches, such as fleur-de-lis, upper lateral thoracic lift or bra-line backlift.

In case of an indication for a breast and arm lift the lateral and dorsal thoracic wall has to be evaluated. The ideal indication for an upper body lift is the presence of lateral and dorsal thoracic skin folds, which can be eliminated by a lateral thoracic approach. It has to be considered that the lateral soft tissue excess can be used as an autologous tissue augmentation for breast reshaping procedures in female patients. On the contrary, in male patients this tissue excess has to be resected without exception.

Surgical Technique

Upper Lateral Thoracic Lift

The conventional surgical treatment of the upper two back and lateral rolls by direct excision at the aspect of the dorsal thorax often leads to wide, unsightly and permanent visible scars. Respecting the different interfering units of the upper body, and in terms of reduction of operating and recovery time and improving patient outcome, we combine the upper arm lift with breast reshaping and the upper-lateral thoracic lift as an integrated treatment in appropriate cases. Using the combination technique, a continuous approach is performed from the medial submammary fold via an anterior and posterior axillary incision line distally to the elbow. In this regard, the circumferential vectors eliminate the upper breast and lower scapular rolls and a horizontal tension to the central zone over the vertebral column is ensured (Fig. 17.3).

FIG. 17.3 Preoperative posterior, lateral and anterior view of a 39-year-old woman after 100 kg weight loss due to gastric bypass.

Starting with the upper arm lift, which is mostly performed in terms of the double-ellipse technique as described by Aly,² we continue passing the axillary crease. The upper-lateral thoracic lift is followed in terms of a direct and indirect excisional procedure, mobilizing the dorsal and lateral thorax region. In female patients, we preferably address the breast deformities in a 45–60° upright patient positioning, performing the Rubin technique with a central pedicle and cranial fixation to preserve volume and prevent bottoming out, which is a common complication in this patient group due to the extremely thin atonic skin quality. In male patients, we generally perform the excisional technique with a pedicled breast reduction with simultaneous liposuction, resulting in best achievable results in this patient group. This intraoperative sequence ensures that the nipple–areola complex is not set too laterally and that you are able to compensate for the lateral pull being created with the upper-lateral thoracic lift. In the axillary crease the running scar may be disrupted with a Z plasty to prevent postoperative scar contraction.

In summary, it can be emphasized that the upper lateral thoracic lift is a safe and effective procedure to simultaneously reduce upper lateral thoracic and upper back rolls without placing a single scar to the back region. It can be performed as a single procedure or an integrated part of a combined technique for restoration of the upper arm, lateral as well as dorsal thorax, and the breast.

After carefully pinching and setting clamps and staplers for tailor tacking we can control the lateralization of the breast and may adjust the position of the nipple–areola complex. Usually we leave the staplers in place and start with the arm first. We stop our incision at the level of the axilla. We continue with the mastopexy procedure and stop our incision at the anterior axillary line.

Then we start incising at the curved ventral line of the lateral thoracic region. As there is no clear definition of the superficial fascia at this level we do not perform preparation too deep and we preserve a thin layer of fat epifascial to the deep fascia. This reduces the risk of injuring underlying nerves such as the lateral-thoracic nerve and lower intercostobrachial branches.

Once the incision has been made and the preparation has been completed up to the dorsal resection line we carefully pull the ventral wound edges dorsally, estimating if the breast shows a tendency to move laterally. In cases of extended lateralization we suture the deep layer of the ventral wound edges down to the deep muscle fascia, using PDS 2-0 sutures (Ethicon, USA). Then we pull the dorsal flap over the ventral wound edge and complete the resection. Before temporary closure with staples and suturing of the wound, we fixate the dorsal wound edge to the deep fascia for definition of the submammary fold, using PDS 2-0 sutures.

We do not primarily apply a Z plasty at the axillary crease in every case. However, if contraction at this level becomes evident during the postoperative period, this procedure can be considered in cases of conservative treatment failure.

Optimizing Outcomes

Since patients after massive weight loss often present with skin and soft-tissue redundancy in the upper arm, lateral thorax, and the breast regions, most of these patients desire corrections in these adjoining parts of the upper body. In Germany, body contouring cases after massive weight loss may be reimbursed by general or private insurance based on the DRG-system. Since the breast and lateral chest regions are interacting regions that, for example, may provide soft tissue for autoaugmentation of the breast, a combined reconstruction of these regions is unavoidable. Hence, a staged reconstructive procedure of the upper arm may be performed without affecting the upper trunk region.

Due to steady technical improvements, upper body lift procedures enable plastic surgeons to treat the upper truncal contour sufficiently to rapidly reach patients’ goals and expectations, with a reduced total recovery time. The upper body lift has gained wide popularity in the group of massive weight loss patients, nowadays performed as a routine part of a body reconstruction concept after weight loss.

In general, dependent on the preoperative BMI and existing folds, indications for direct excisional procedures of the back are rarely seen in patients with mild to moderate weight loss, but occasionally in patients after massive weight loss. Although satisfactory results can be achieved with this approach, unfavourably located scar placement and scar quality restrict the implementation of this procedure, especially in male patients.

A more common and favorable procedure for contour improvement of the dorsal thoracic region is the upper-lateral thoracic lift, intended for patients after massive weight loss with consequent skin and soft-tissue redundancy in the lateral and dorsal thoracic region with or without lateral and back folds. It enables sufficient tissue elimination in different neighboring regions, conventionally seen as different anatomical units, by optimal scar placement. Optionally, this can be performed alone or as an integral part of a combined contouring procedure of the upper arm, the lateral and dorsal thoracic wall, as well as the female or male breast. In female patients it is usually combined with an inverted-T pattern breast reshaping, elongating the submammary incision to the axillary crease. In male patients we perform the direct excisional procedure for breast reshaping after massive weight loss, optionally with a free nipple graft, as popularized by Aly or as a pedicled transfer as recently described by Gusenoff or Stoff.^2,10,11 The submammary scar is ideally placed at the inferior boundary of the pectoralis major muscle, continuing well hidden at the lateral thoracic wall to the axillary crease.

Scar formation in upper body contouring is well accepted by patients, though results differ widely in quality and appearance due to atonic skin quality with poor elasticity after significant damage to extracellular matrix components during obesity and bariatric surgery.¹² In this regard, patients should be told clearly about revisional surgery, since the rate for secondary corrections in this patient group is relatively high due to secondary skin and tissue relaxation.

Some representative case studies are shown in Figs 17.4–17.8.

FIG. 17.4 12-months postoperative posterior, lateral and anterior view after circumferential lower truncal dermatolipectomy, breast and bra-line lift.

FIG. 17.5 Marking of the lateral thoracic lift incision lines by lateral pinching. The lower incision line should extend to the back region to allow maximal tightening of the back and lateral rolls. The dotted line presents the estimated scar course.

FIG. 17.6 Preoperative posterior, lateral and front view of a 42-year-old patient after 70 kg weight loss.

FIG. 17.7 3-months Postoperative posterior, lateral and anterior view after circumferential lower truncal dermatolipectomy with skin folds remaining in the upper lateral and dorsal trunk.

FIG. 17.8 12-months postoperative posterior, lateral and anterior view after circumferential lower truncal dermatolipectomy, breast reshaping and upper lateral thoracic lift.

Postoperative Care

The postoperative management after upper body lift procedures is similar to lower body lift procedures (see Chapter 38). However, patients are not monitored on the intensive care unit. Early patient mobilization from day 1 with adequate thrombosis prophylaxis from low molecular weight heparin and a specially adjusted compression garment for 8 weeks postoperatively are mandatory.

In all cases we support postoperative wound healing and reduction of lymphatic swelling, particularly in the area of the lower arms, through early lymphatic drainage.

For further details please refer to Chapter 38.

Complications and Their Management

Complications can be differentiated into minor and major as well as early and long-term complications. Compared to body contouring procedures of the lower body regions, seroma formation is observed less frequently in the area of the breast and arms. In the lateral chest and axillary region seroma formation may occur more often in cases of radical fat tissue resection, especially the deeper fatty layer overlying the latissimus dorsi muscle. We emphasize the preservation of the deep layer of fat in the area of the lateral chest and perform resection superficially in the axillary region. Further, we recommend applying wound drains in the breast and lateral chest area. We refrain from drains in the arm regions due to the minimal dead space and low risk of seroma formation.

Minor wound dehiscences and wound healing disorders are frequently observed after major surgical procedures such as the upper body lift. This can occur in the early postoperative phase as well as during the later phase. The causes of wound dehiscence can be assumed to be impaired wound healing, such as in smokers or, in cases of local wound infections, nutritional deficiency or incompatibility with suture material. Further, an undetected seroma can gain a size that leads to wound separation and spontaneous evacuation. Another important aspect for prevention of wound healing disturbances is the placement of subcutaneous suture knots at an adequately deep level. Alternatively, the use of subcutaneous barbed sutures in a running manner may be recommended. One has to be aware that this closure technique requires a learning curve in terms of stability and suturing time.

The key to good scar formation is well-defined skin preparation and the careful tissue handling, an optimized suturing technique and the patient’s compatibility with the suture material. We recommend performing skin closure to a maximal degree of everted wound edges, which will result in reduced tension during the epidermal skin regeneration.

The axillary region presents a slightly higher risk of complications such as wound healing disorders, since mobility and consequent shearing forces in this particular region are higher and hygiene is poorer due to the larger number of sweat glands. Seroma formation can occur particularly in this region due to the risk of damage to the lymphatic system. Again, we therefore emphasize avoiding total resection of the fatty tissue overlying the lateral border of the pectoralis major muscle and anterior border of the latissimus dorsi muscle.

Secondary relaxation, especially in the breast region, is very commonly seen and has to be clarified on the patient’s part. Understanding this postoperative characteristic is essential to achieve adequate patient satisfaction. To avoid the appearance of a postoperative bottoming out we emphasize the positioning of the new nipple–areola complex in relation to the submammary breast fold. In this context, the new sternal–areolar distance may range from 21 and higher, defined in relation to the sternal–submammary distance. Postoperative bottoming out therefore derives from an inadequate sternal–areolar distance.

For further information please refer to Chapter 39.

Conclusion

The upper body lift procedure allows a simultaneous reshaping of the upper arms, axillary region, lateral chest, lateral back, breast and upper abdomen in selected cases. The combination of these procedures enables a significant reduction of patients’ total recovery and down time, with a consequently reduced financial burden to the health and welfare system.

Operation time can be significantly reduced through precise preoperative marking and a standardized peri- and intraoperative setting. Ideally, the operative implementation should be managed by two surgical teams, reducing preparation and wound closure time. Postoperative standards in patient care should guarantee optimal progress and patient safety.

In cases of breast hypoplasia after massive weight loss it is mandatory for the plastic surgeon to inform patients about the increased risks of complications caused by silicone implants. In a high number of patients after massive weight loss the recruitment of excess tissue from the lateral chest and upper abdomen allows a significant volume augmentation without the side effects of silicone implants. The combination of tissue tightening in the adjoining regions of the breast, upper abdomen and lateral chest with simultaneous autoaugmentation of the breasts is best accomplished during the upper body lift procedure.