10.2.1 Weight Stability

Patients after bariatric surgery lose most of their weight during the first and second year after the procedure. ⁷ Patients typically reach a nadir and then plateau at a slightly higher weight. Body contouring after weight loss typically is deferred until the patient is at least 12–18 months out from her weight loss surgery or start of self weight loss and has been stable for 3 months with only approximately 5 lb (2.25 kg) of weight fluctuation over that time. ^{8 ,​ 9} Patients who are not yet weight stable or who have residual obesity are typically referred to weight loss specialists or their bariatric team, with a scheduled follow-up in 3 months for re-evaluation.

10.2.2 Nutrition

Certain bariatric procedures, such as the Roux-en-Y gastric bypass, have a malabsorptive component in addition to the restrictive nature of the surgery. Care must be taken to assess and correct nutritional deficiencies, as this is crucial for wound healing and minimizing the need for blood transfusion. All patients should have a thorough evaluation including albumin, prealbumin, iron, and vitamins A, D, E, K, and B₁₂. Protein malnutrition may be present, especially for patients with malabsorptive procedures or fad diets. Patients are guided to increase their protein intake perioperatively with a goal of 75–100 grams per day.

10.2.3 Body Mass Index

Obesity is defined as body mass index (BMI) greater than 30 kg/m². Several investigators have reported an increased risk for complications in patients undergoing body contouring procedures with a body mass index greater than 30 kg/m². ^{10 ,​ 11 ,​ 12 ,​ 13 ,​ 14} A large cohort study of MWL patients undergoing multiple procedures demonstrated complications associated with maximal BMI prior to weight loss and change in BMI, or delta BMI. However, the exact etiology of this is not well understood, as many factors can contribute to complications. In addition, no strict BMI cutoff was determined to influence complications. ¹⁵ For this reason, the authors advocate for examining patients for breast contouring procedures on an individual basis, as a patient with a high BMI may have very deflated breasts but carry most of her excess weight in a pannus or thighs, which are not the patient’s priority or goal. Patients with lower BMI around the time of surgery typically obtain better cosmetic results, and patients with a BMI greater than 35 kg/m² are not uncommonly referred for further weight loss prior to proceeding with surgery.

10.2.4 Preoperative Assessment and Comorbidities

At consultation, a complete medical and surgical history is obtained, including any personal or familial history of coagulopathies or thrombotic events; former problems with anesthesia; and history of breast cancer, breast disease, or prior breast surgery. Detailed medication history includes all prescription, over-the-counter, and herbal medications and specifically the use of aspirin, other nonsteroidal anti-inflammatory drugs (NSAIDs) or any other medication that might increase the risk of bleeding postoperatively. A history of substance abuse or need for chronic pain medication is obtained. Many of the comorbidities associated with obesity will resolve or improve with bariatric surgery, such as diabetes, sleep apnea, hypertension, heart disease, and gastroesophageal reflux disease (GERD) ^{16 ,​ 17 ,​ 18} ; however, depression and anxiety may not improve. Patients are often referred for consultation for various residual comorbidities, such as hematology evaluation for iron deficiency anemia, or to medical specialists for clearance for surgery (such as internal medicine, cardiology, or psychology).

Smoking increases the risk for surgical complications, and all patients should stop smoking for at least 4 weeks prior to and after surgery. ^{10 ,​ 19 ,​ 20 ,​ 21} This is especially important for flap survival and prevention of distal flap necrosis. Urine cotinine prior to surgery is routinely measured in patients who state they have recently quit smoking.

Complete physical examination with a comprehensive breast exam and assessment of the position of the IMF, quality of skin, degree of ptosis and nipple position, amount of breast tissue, asymmetry, and adjacent tissue excess is mandatory.

Preoperative laboratory workup includes complete blood count with platelets, complete metabolic panel (including albumin), prothrombin, and activated partial prothrombin time within 30 days of surgery. Urine pregnancy testing is done in all reproductive-age women on the morning of surgery.

Chest radiograph and electrocardiograms are ordered as indicated by age and medical profile. All patients above 40 must obtain a mammogram prior to surgery.

Preoperative photography is obtained in standing position with anterior, lateral, and oblique views from the lower neck to the waist. Photographic documentation is important to analyze and plan the procedure properly as well as to document preoperative asymmetry and surrounding soft tissue deformities that may become more noticeable after the breasts are contoured.

During the consent process, it is important to make sure the patient has realistic goals and understands the limitations of plastic surgery, including possible asymmetry postoperatively and recurrent skin laxity despite how tight the tissues are in surgery. Managing expectations ahead of surgery can avoid significant patient and surgeon disappointment postoperatively.

10.2.5 Staging and Combination of Body-Contouring Procedures

Breast contouring after MWL is often done as a solo procedure; however, adjacent body areas may need contouring as well. Patients and the surgeon may opt to perform multiple procedures, depending on the patient’s desires, financial abilities, comorbidities, nutritional status, and ability to withstand a lengthy operation and recovery and on the surgeons’ experience and the available team.

When combining procedures, keep in mind the following: ^{22 ,​ 23}

• 
  

  Pulling in opposite vectors at the same time can limit results.

  
  
• 
  

  Patient safety comes first: if medical comorbidities preclude a lengthy operation, the surgical plan may need to be changed.

  
  
• 
  

  Consider the magnitude and stress of recovery when combining procedures.

  
  
• 
  

  Optimal staging and combination of procedures may not correspond with patient’s preferences.

Favorable procedure combinations including the breast are ¹⁰

• 
  

  Abdominoplasty + mastopexy: a common combination that gives the patient a powerful transformation.

  
  
• 
  

  Circumferential lower body lift + mastopexy.

  
  
• 
  

  Upper body lift + mastopexy: eliminating the upper body lift “dog-ears” while merging the incisions together.

  
  
• 
  

  Brachioplasty + mastopexy: curving the lateral chest incision into the axilla.

  
  
• 
  

  Vertical thigh lift + mastopexy.

Caveats for combining breast and other body contouring procedures:

• 
  

  Mastopexy may be safely combined with an abdominoplasty with excellent results. Since the IMF on the MWL breast is very loose and mobile, especially laterally, it may be displaced inferiorly upon completion of the abdominoplasty, requiring the surgeon to adjust the mastopexy markings. ^{10 ,​ 22} Similarly, addition of a fleur-de-lis vertical extension to an abdominoplasty can mobilize the inframammary fold inferomedially. Hence, it is wise to complete the abdominoplasty before proceeding with the mastopexy. In cases where the IMF is completely nonadherent to the chest wall, it would better serve the patient to separate these two procedures completely.

  
  
• 
  

  Be careful of fresh triple point incisions, such as when combining an upper body lift + dermal suspension parenchymal-reshaping mastopexy + brachioplasty; these areas tend to break down and cause wound healing problems. ^{10 ,​ 22} The mastopexy can be performed merging in the brachioplasty scar at the lateral chest, or merged into the upper body lift, delaying either the upper body lift or brachioplasty until a later time.

10.3.1 Advantages of This Technique

• 
  

  The method is safe with reliable, long-lasting, reproducible results and a low complication rate.

  
  
• 
  

  It uses all the available breast tissue and surrounding autologous tissue (as needed), avoiding the need to use breast implants with their associated morbidity and tendency to descend over time or develop ptosis of natural tissues over the implant.

  
  
• 
  

  It repositions the NAC on the chest wall, securing its position intraoperatively with ease, with less chance of bottoming out thanks to the secure suspension to the chest wall.

  
  
• 
  

  It enables the surgeon to shape the breast parenchyma, restoring upper pole fullness and mammary projection.

  
  
• 
  

  It enables the surgeon to reshape the skin envelope of the breast without relying on it for support of the breast tissue and NAC position.

  
  
• 
  

  It improves the lateral chest contour by eliminating the lateral skin roll and re-creating a discrete lateral curvature.

  
  
• 
  

  It may be combined with other body-contouring procedures safely.

10.3.2 Disadvantages of This Technique

• 
  

  It requires longer operation times because of extensive de-epithelialization and intraoperative tailoring (a two-team approach increases efficiency and decreases operative time).

  
  
• 
  

  It cannot be easily combined with an implant for further augmentation. The patient must have enough autologous tissue available for auto-augmentation. Should the patient desire additional volume, a subpectoral augmentation may be added in a separate future procedure.

10.3.3 Relative Contraindications

• 
  

  Active tobacco users are at risk of flap necrosis.

  
  
• 
  

  Patients with previous breast surgery are at risk of inadequate perfusion to undermined tissues.

  
  
• 
  

  In non-MWL breasts, tight parenchymal reshaping or skin closure can increase risk of parenchymal or skin necrosis.

10.3.4 Markings

The patient is marked in a standing position, based on an extended Wise pattern marking with a central pedicle.

1. 
   

   Mark the sternal notch and midline.

   
   
2. 
   

   Mark the breast meridian: at the midclavicle (approximately 6 cm from the sternal notch), a line is dropped toward the IMF. In many MWL patients, the breast meridian will not be in line with the nipple, as the nipple is often medialized.

   
   
3. 
   

   Mark the new nipple position on the breast meridian: Pitanguy’s point is projected forward by placing a hand at the level of the IMF and projecting the point forward. In patients with very descended IMFs, this point may need to be elevated slightly, but care should be taken not to overelevate the IMF and thus the new nipple position. Check for symmetry.

   
   
4. 
   

   Mark the extended Wise pattern:

   
   
   
   
   1. 
      

      The superior part of the keyhole (representing the new upper border of the areola) is placed 2 cm above the new nipple position.

      
      
   2. 
      

      7-cm vertical limbs are drawn from the new nipple position. The keyhole is then designed extending from the point 2 cm above the new nipple position to 2 cm down each vertical limb. This maintains a 5-cm vertical limb that represents the new inferior nipple-to-IMF distance. An 8-cm base (angle of divergence) is planned. If the patient has more dense breast parenchyma, the angle of divergence may be narrowed, reducing the amount of parenchyma internally for reshaping and increasing the amount of skin externally. In addition, the vertical limbs can be extended to increase the estimated length from the bottom of the nipple to the IMF (Fig. 10‑2).

      
      
   3. 
      

      Mark the medial point of the extended Wise pattern: typically, at the takeoff of the breast.

      
      
   4. 
      

      Mark the IMF: a “cheat” may be marked at the middle part of the central pedicle (along the breast meridian) to further reduce tension at the T point junction further. If not needed, it can be de-epithelialized prior to incision closure.

      
      
   5. 
      

      Mark the lateral point of the Wise pattern: this will determine how much of the axillary roll will be de-epithelialized and incorporated into the breast for auto-augmentation. Tissue is routinely taken and consistently reliable to the mid-axillary line. Excision may be extended to the posterior axillary line and farther to improve contour of the lateral chest wall.

      
      
   6. 
      

      Connect the lateral point to the vertical limb of the Wise pattern in a curvilinear line: this conserves more tissue medially and creates a larger takeout laterally.

   
   
5. 
   

   Mark the second and third ribs bilaterally.

   
   
6. 
   

   Mark the superior footprint of the breast by pushing up on the breast to simulate the upper boundary of the breast.

   
   
7. 
   

   Check for symmetry in the markings between the breasts (Fig. 10‑3).

   

   

Preoperative asymmetry in nipple position is taken into consideration during the markings to avoid asymmetric nipple placement during the dermal suspension. To correct for the asymmetry, the keyhole markings are the same bilaterally, but less tissue is de-epithelialized on the side of the lower nipple to account for the discrepancy. The excess skin above this new point is excised (Fig. 10‑4).

10.3.5 Surgical Technique

The patient is placed in the supine position, arms abducted to 90°. Care is taken to secure the arms to padded arm boards, as the patient will be in a near-sitting position for a large part of the surgery.

1. 
   

   Mark the areola with a 42-mm nipple washer or cookie cutter.

   
   
2. 
   

   Superficially inject a local anesthetic solution (epinephrine 1:100,000) to areas of de-epithelialization (the entire region within the Wise pattern, excluding the NAC).

   
   
3. 
   

   De-epithelialize the entire extended Wise pattern with its extensions medially and laterally.

   
   
4. 
   

   Mark a 10-cm-wide central pedicle at the base of the breast starting 7 cm from the most medial point of the extended Wise pattern (Fig. 10‑5).

   
   
5. 
   

   Use electrocautery to score all around the Wise pattern markings to reach breast parenchyma, excluding the 10-cm base of the central pedicle inferiorly (Fig. 10‑6).

   
   
6. 
   

   The upper breast flap is then raised with a 1- to 1.5-cm thickness until the chest wall is reached. Undermining along the breast meridian continues until the second rib is clearly palpable. A subcutaneous pocket is created, into which the breast tissue—which is now isolated on a central mound as a dermoglandular flap (with robust blood supply)—will be transposed as it is being shaped. Care should be taken not to overdissect medially, as this can result in a symmastia appearance of the breasts. Similarly, the lateral attachments of the upper flap should be released only as needed to accommodate the newly constructed breast mound (Fig. 10‑7).

   
   
7. 
   

   The lateral and medial dermoglandular flaps are then elevated off the chest wall at the level of the fascia over the chest muscles, preserving as many significant perforating vessels as possible near the flap base. Care is taken to check routinely that the 10-cm central pedicle thickness is preserved, as it can easily be undermined unconsciously in a much-deflated breast. The authors typically limit the lateral extent of the dermoglandular flap to the mid- or posterior axillary line, since incorporating tissue distal to that point carries the potential risk of fat necrosis. Trim the lateral flap as needed for auto-augmentation, discarding distal tissue removed for contour purposes (Fig. 10‑8).

   

   

   

   

Related posts:

7 Preoperative Evaluation of Patients with Macromastia and Ptosis 11 Internal Bra Technique in the Breast with Poor Soft Tissue Support 12 Reduction Mammaplasty 8 Mastopexy Techniques—Basic Principles 9 Augmentation and Mastopexy—Basic Principles to Develop a Treatment Plan and Technical Pearls 22 Nipple Areolar Procedures and Aesthetics

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