27 Bra-Line Back Lift

10.1055/b-0034-80636

27 Bra-Line Back Lift

Hunstad Joseph P. Urbaniak Roderick M.

Abstract

Laxity and redundancy of the skin and subcutaneous tissue of the upper back can be very bothersome and unsightly for both the massive weight loss patient and many nonobese patients. Sun exposure, weight fluctuations, and increasing age are the main factors contributing to this deformity. Patients express considerable concern about this tissue redundancy when it creates visible irregularities, particularly when wearing form- fitting clothing. A bulge above, a depression at, and a bulge below the bra line are very disconcerting to many patients. Traditionally, this area has represented a considerable challenge for plastic surgeons, as lower-body contouring procedures, such as a circumferential abdominoplasty or body lifting, fail to treat this area. The strong force exerted by buttock and flank lifting does not extend to the upper back because of the very robust midline zone of adherence.1–8 Several anterior upper trunk procedures such as reduction mammaplasty and mastopexy can address this area indirectly if extended posteriorly enough, but we report the bra-line back-lift technique that has been specifically designed to eliminate upper back laxity and redundant tissue so bothersome to many patients.9–12 The surgery involves resection of skin and fat through an incision that is placed in the bra line. It is a highly effective procedure with a minimal downtime that can be used as an isolated procedure or in combination with reverse abdominoplasty, mastopexy, or reduction mammaplasty. This treatment has been associated with a very high level of patient satisfaction and a remarkably low complication rate.13

Introduction

The bra-line back lift (BLBL) procedure was developed to specifically address skin laxity and excess adiposity of the upper back. Many patients, even those in excellent physical condition, experience skin laxity and excess adiposity of the upper back. This malady manifests itself as bulges above and below the bra line that are very disconcerting to patients. Some procedures of the anterior trunk can be extended to incorporate lateral upper back redundancy, including mastopexy, reduction mammaplasty, and reverse abdominoplasty, but none target this area exclusively. The BLBL procedure presented here, first performed by the senior author (J.P.H.) in 2001, was created specifically to address the deformity.13 It involves resecting skin and subcutaneous tissue while placing the final incision line beneath the bra line. This operation is ideal to treat the upper back because it achieves complete correction of upper back laxity. The morbidity associated with the procedure has been minimal and patient acceptance extremely high.

Indications

Good candidates for the BLBL are women with undesirable skin laxity, skin redundancy, and excess adiposity of the upper back that result in unsightly rolls and folds. This can include massive weight loss and nonobese individuals alike. Patients are frustrated and aggravated with this laxity and excess adiposity, particularly in conforming, tightly fitting clothing. This tissue can be seen to bulge above and below the bra line, resulting in multiple rolls and folds along the lateral aspects of the upper back.

**Fig. 27.1 (A,B)** Oblique views are also helpful but not as dramatic as the posterior view.

Unfortunately, these problems are not amenable to diet management or exercise and occur in both the massive weight loss patient group and in many normal-weight patients.1–7 The BLBL procedure, performed separately or combined with breast lifting, reduction, or reverse abdominoplasty, offers a complete correction of upper back disharmony with dramatic results and a low complication rate.

Technique

Markings

Patients presenting for this procedure often grasp the excess skin of their upper back and request that it be eliminated. For these patients, standard preoperative photographs are taken of the posterior, lateral, and posterior oblique views ( Fig. 27.1 ). The patient is asked to wear her most revealing bra to the consultation, and this bra is outlined for use as a template ( Fig. 27.2 ). The bra is then removed, and the final incision line is designed to be concealed within this garment. The incision courses from the left to right anterior axillary lines and usually is continuous with the inframammary fold ( Fig. 27.3 ). Extending the incision this far anteriorly ensures completely flat flanks and paucity of fullness or dog-ears lateral to the inframammary fold. Strong bimanual palpation is then performed to identify the redundancy across the entire incision line, ensuring that the final scar placement is correct ( Fig. 27.4A–C ). This redundancy is marked in three key locations: in the midline, along the scapular tip, and along the posterior axillary line. Typically, the midline redundancy is slightest, due to the strong zone of adherence, whereas the redundancy is greatest in the posterior axillary line ( Fig. 27.4C,D ). Laterally, the proposed excision is tapered to end at the inframammary fold in the usual fashion, avoiding a dog-ear ( Fig. 27.4E ). Realignment marks are placed to ensure precise vertical closure. Patients are asked to review the final incision line to ensure that they are in agreement with its location and length. This eliminates postoperative confusion regarding final scar position and length.