85 Postbariatric Body Contouring: Upper Back Contouring—The Bra-Line Back Lift

Joseph P. Hunstad and Matthew H. Isakson

Abstract

The bra-line back lift is a powerful technique that addresses the entirety of the complex back deformity following massive weight loss. The zones of adherence in the back result in horizontal and vertical laxity, particularly after massive weight loss, which is not treated by a traditional lower body lift or other techniques. The bra-line back lift allows the surgeon to address this deformity with a horizontal scar that is well tolerated and easily concealed in a brasserie or swimsuit top. Complications are rare and can usually be managed with minor revision and wound care. The procedural learning curve is gentle, yielding consistent and predictable results with high patient satisfaction.

Back lift – torsoplasty – trunkplasty – bra-line back lift – upper body lift – transverse upper body lift

85 Postbariatric Body Contouring: Upper Back Contouring—The Bra-Line Back Lift

Key Points

The bra-line back lift is a powerful technique that allows the surgeon to address the entirety of the complex back deformity, including excess adiposity and skin laxity.
Zones of adherence in the upper back result in horizontal and vertical laxity that are not addressed by a traditional lower body lift.
The bra-line back lift allows the surgeon to address this common upper back deformity with a scar that is well tolerated and easily concealed in a bra or swimsuit top.
Morbidity has proven to be minimal. Complications are rare and can usually be managed by minor wound care or revision under local anesthetic.
The procedural learning curve is gentle, yielding consistent and predictable results with high patient satisfaction.

85.1 Preoperative Steps

85.1.1 Counseling

A comprehensive discussion regarding body contouring and goals is held with the patient. Photographs are reviewed with patients to ensure expectations are appropriate, and they understand incision placement, risks, and complications.
Routine labs including complete blood counts, comprehensive metabolic panels, and coagulation profiles are drawn and reviewed.
Discontinue nonsteroidal anti-inflammatory medications and herbal supplements 2 weeks before surgery. Smoking abstinence should be reviewed with patients; active nicotine abuse is a relative contraindication.

85.1.2 Analysis and Marking

Patients with concerns of upper back tissue excess are evaluated for skin quality, striae, subcutaneous adiposity, and excess or hanging skin.
Redundant tissue is firmly grasped with bimanual palpation to demonstrate the final outcome in terms of tissue resection. Patients are encouraged to bring their most revealing top or bra the day of surgery to individualize scar placement.
Patients are marked in a standing position with their arms at their sides.
Bimanual palpation is used to strongly gather redundant skin and adiposity such that it centers on the final incision line. The resection pattern is strongly tapered into the inframammary fold at the level of the anterior axillary line to prevent a dog-ear.
Precise realignment of tissues is important to the ultimate outcome, and closure is facilitated by vertical realignment marks placed preoperatively (Fig. 85.1).

**Fig. 85.1** Bra-line back lift preoperative markings.

85.2 Operative Steps

A penetrating towel clamp is used to the confirm preoperative markings and assess tension at multiple points. Difficulty in closing the clamp signifies excessive tension and adjustment of these lines is common.
Realignment markings are tattooed with methylene blue as “permanent” skin markers rarely provide markings that last the entirety of a case.
Dissection proceeds, without beveling or undermining, straight down to the loose areolar plane above the muscle fascia. The tissue directly superficial to muscle fascia is preserved to help with pain control and to provide an anchor for space-obliterating sutures.
Accurate bites of the superficial fascial system (SFS) are of vital importance to the closure. Tension is maximal on the SFS and immaculate closure will prevent scar migration or widening. The SFS may seem to retract in relation to the overlying dermis when the towel clamps are placed.
Based on tension, either a 0 or number 1 polyglactin (Vicryl, Ethicon Inc, Somerville, NJ) suture is used. The closure begins laterally and progresses toward the spine. This suture is a three-point, space-obliterating suture, eliminating the need for drains.
Towel clamps or staples can be progressively used at selective points of higher tension closure in order to ensure that good opposition is secured.
The deep dermis is closed with a 2–0 polyglactin (Vicryl) suture in a buried fashion. The final layer is finished with an intracuticular running 4–0 poliglecaprone suture (Monocryl, Ethicon Inc, Somerville, NJ).
Should this procedure be combined with a mastopexy, breast reduction, or reverse abdominoplasty, a temporary V-Y closure can be performed anterolaterally as far as the table permits.
The suture line is then treated with paper tape; it is important to split the tapes every 3 cm to allow for swelling and to avoid shearing forces. If tape is not split, the skin will shear resulting in blistering and postinflammatory hyperpigmentation.