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