Introduction

A subset of massive weight loss (MWL) patients presents with complaints of significant rolls along the upper back and lateral chest. These back rolls often merge with the lateral skinfolds of the chest and into the lateral inframammary fold (IMF). In Lockwood’s1 description of the superficial fascial system (SFS), a strong zone of adherence of this layer to the vertebrae and to the sternum was demonstrated. Following MWL, there is minimal tissue laxity in the anterior and posterior midlines due to these zones of adherence; however, there is increasing skin laxity with lateral movement from the midline. This can result in a characteristic inverted-V deformity on both the anterior and posterior trunk that connects in the axillary region. The location and severity of these deformities dictate how these regions will be corrected.

There is little historical basis for this procedure because its popularity has paralleled the recent increase in bariatric surgical procedures. This anatomy has not been an area of focus for plastic surgeons, but as more patients are presenting for postbariatric body-contouring procedures, reliable techniques to produce a pleasing aesthetic contour of the back have become necessary. Because the deformities in this region frequently result from redundant skin and subcutaneous tissue, liposuction is often an ineffective technique to correct the contour. Excisional techniques are most often used to correct the back and lateral chest rolls. Some authors advocate rotating the skin excess from the posterior trunk anteriorly to the breast for autologous augmentation.2–4 Others directly excise and discard the excess tissue, in either a transverse or an oblique approach.5–8 Excision of the tissue in the midaxillary line has also been described to correct the redundancy of the posterior trunk, as well as the ptosis of the subaxillary lateral chest wall.9

Our preferred technique involves a transverse excision of skin and tissue in a transverse manner that can easily be hidden beneath a brassiere. Based on Lockwood’s concept of the anchor line, we have developed a technique that can accurately predict the placement of the scar on the posterior trunk. We prefer a transverse excision to an oblique excision because we believe the entire back can be recontoured through this excision, and the “dog-ear” can be chased ante-riorly to correct the lateral chest wall deformity and merged either into a mastopexy incision, if being simultaneously performed, or simply into the IMF. We also prefer the aesthetic appearance of a transverse incision line that can be hidden beneath a brassiere. Although the lateral excision technique to correct the posterior trunk does not place an incision line on the back, significant undermining of the back subcutaneous tissue is necessary to adequately mobilize the tissue to flatten these rolls. This results in large dead space and increased risk for seroma.

Indications

Patients who have multiple skin rolls of the back and lateral chest are good candidates for an upper body lift (UBL). There is considerable variation in the presentation of these deformities, and the consultation must be individualized to each patient. The main goal of the UBL is to correct the horizontal skin excess that exists on the posterior trunk and lateral chest wall. Given the degree of excess following MWL, these areas are often not adequately treated by liposuction and require excision.

Patients who are good candidates for this procedure should be near their goal weight and should be weight stable for a minimum of 3 months. Because this is considered an elective cosmetic procedure, we prefer these patients to have a favorable body mass index (BMI). In our experience, this procedure has traditionally been performed during a second or third stage and has been combined with mastopexy, breast reduction, or brachioplasty. It can also be done as an isolated procedure.

The decision as to which procedure to perform depends on two main factors: (1) the location and extent of the deformity and (2) the desired scar location. Patients with isolated back rolls or those who have residual skin excess on the back following an extended Wise-pattern breast-contouring procedure in a first stage may benefit from direct excision. This can be performed in either an oblique or a transverse manner depending on the deformity. Patients who have not had previous contouring of the breasts and arms have varying degrees of laxity in these regions and the axilla. These patients are good candidates for a transverse UBL. In patients who are having only a UBL, the dog-ear from this procedure can be followed into the IMF. In patients who are undergoing a combined mastopexy or breast reduction, the dog-ear is followed into the lateral extension of the Wise pattern. This procedure can also be performed with a brachioplasty. When this combination is performed, we attempt to keep the axillary extension of the brachioplasty separate from the UBL incision to prevent confluence of the scars.

As with every patient presenting to our clinic for body contouring following MWL, a thorough history is taken, and a physical examination is performed. Nutritional status is evaluated and optimized prior to surgery.10 We have a low threshold for medical consultation as clinically indicated. Relative contraindications are high BMI and smoking. Active smokers are deferred for surgery until they have stopped for a minimum of 4 weeks. Smoking cessation is confirmed by urine cotinine testing.