Chapter 13 Breast reshaping after massive weight loss
Autologous tissue techniques
• Careful assessment of parenchymal volume, amount of redundant skin envelope, and extent of lateral skin/fat roll is necessary for planning the procedure. Importantly, medial displacement of the nipples is a common finding in the massive weight loss patient.
• The spiral flap procedure uses adjoining lateral thoracic and epigastric flaps. The de-epithelialized lateral thoracic flap, supplied by intercostal trans-serratus perforators, takes a spiral course to augment the superior pole of the breast over the pectoralis major muscle and is suture suspended to the third costal cartilage. The de-epithelialized epigastric flap is supplied by descending branches from the sixth intercostal and flips up to augment the inferior pole of the breast and is suture suspended to the fifth costal cartilage.
• The dermal suspension mastopexy involves de-epithelialization of an extended Wise pattern with elevation of medial and lateral fasciocutaneous flaps, auto-augmentation using the lateral flap, suspension of flaps to rib periosteum, and parenchymal reshaping by plication of the broad dermal surface.
Female breasts undergo dramatic changes after massive weight loss (MWL), with volume loss, deflation of the skin envelope, and ptosis. Poor tissue quality and loss of esthetic units make the MWL breast not only difficult to beautifully shape, but also prone to recurrent deformity. Complicating the MWL breast deformity is the surrounding loose skin of the arm, axilla, and torso. As an evolving paradigm of mastopexy after weight loss, the surrounding soft tissues can be repositioned to improve breast volume and shape. This can be done in a coordinated manner with other upper body contouring procedures.
Typically, the breasts flatten, sag and descend on the chest. Superior pole fullness is almost nonexistent. The breasts are displaced and broadened by descended inframammary folds (IMF). The IMF descent progressively increases from medial to lateral. The nipple–areola complexes (NACs) are ptotic and usually distorted and medially displaced. Surrounding the breasts are rolls of mid torso skin shaped by transverse subcutaneous fascial adherences to underlying muscular fascia. This manifests as characteristic lateral rolls that obliterate the lateral curvature of the breast and blend the breast seamlessly with the upper torso.1
The strategy for correcting the breast deformity in the MWL patient considers the degree of NAC ptosis, current and desired breast volume and shape, skin quality and quantity, descent of the IMF, neighboring skin deformity, extent of available tissue excess for breast augmentation and suspension, and prior breast surgery. In many MWL patients, the breasts descend 1–4 cm on the chest. As the IMFs approach the costal margins, women admit that they have to uncomfortably pull up their brassieres to raise their breasts. The surface of the posterior aspect of the breast on the chest wall has been called a footprint, which is the “foundation for the overlying three-dimensional structure of the breast”.2 Blondeel et al further subdivide the pertinent breast esthetics into breast conus, skin envelope quality and quantity.2 “The breast conus refers to the three-dimensional shape, projection, and volume of the tissue (or implant) on top and anterior to the footprint of the breast”.2 The determinate issues are volume, shape (breast conus), the breast footprint, the severity of the deformity, the need and acceptance of extensive incisions to correct the breast, and the availability of neighboring tissue for augmentation and suspension. The major goals are central projection and superior fullness, appropriate nipple positioning, and three-dimensional shaping that restores the lateral curvature of the breast.
Two techniques are highlighted in this chapter: spiral flap reshaping and dermal suspension mastopexy with auto-augmentation. Both techniques can treat inadequate breast volume with transposition of nearby soft tissue excess.
In the spiral flap technique, excess skin and fat of the epigastrium and lateral thorax are de-epithelialized in continuity with the central breast mound and appropriately positioned, then tailored and buried under Wise pattern flaps.3 The inevitable twisting and turning of this compound flap led to the name “spiral flap”.4 The epigastric flap is an inferior extension of the central breast pedicle nourished through descending intercostal perforating vessels. The lateral chest flap is a tongue-like lateral fasciocutaneous extension of the central pedicle, similar to the lateral thoracic flap described by Holstrom in 1987 with confirmed utility and safety.5–8 It is a fasciocutaneous flap based on perforators through the serratus muscle. Borud based his breast reshaping after MWL on this flap, which he referred to as the intercostal arterial perforator (ICAP) flap.9 Closure of the donor site removes the lateral chest and back roll, usually leaving a tight transverse closure along the bra line.
The dermal suspension mastopexy10–13 employs a well vascularized central dermoglandular pedicle.14,15 A modification of the traditional Wise pattern allows for the precise control of the skin envelope and nipple position16 with an extended lateral wing of the Wise pattern used to both eliminate the lateral roll and convert the redundant tissue to a fasciocutaneous flap that is transposed into the breast mound. The dermal suspension techniques of Qiao, Frey, Cerqueira and others lay the historical foundation for the use of parenchymal suspension and extensive sculpting via dermal plication and fixation to the chest wall.17–22 Holmstrom’s lateral thoracodorsal transposition flap, as mentioned above, is the basis for auto-augmentation with adjacent chest wall tissues.5 Medial fullness is achieved via the elevation and manipulation of a medial breast flap. Great control over both skin envelope and parenchymal shape may be gained with this procedure.
Both of these techniques have the advantages of correcting the severe breast deformities associated with weight and using regional tissues to augment breast volume. The disadvantages include lengthy scars and longer operative time compared with traditional mastopexy techniques.
Autogenous breast reshaping is offered to MWL women who desire body contouring. They are eligible as soon as 1 year after their bypass surgery, if their weight loss has been stable for 4 months, and if there is no expectation for further weight loss. A thorough review of their medical history, with emphasis on the evolution of obesity-related comorbidities is important. The patient must be under optimal management of their remaining medical diseases with no acute issues.23 Their nutritional status is evaluated and specific mineral, vitamin and protein deficiencies corrected.24,25 Most patients are also started on high protein supplements with a goal of 75–100 g of protein per day. Patients with BMI between 25 kg/m2 and 30 kg/m2 are the best candidates. Moderately obese patients with BMIs between 30 kg/m2 and 35 kg/m2 are advised to attempt further weight loss before surgery and may be at greater risk for wound healing complications.26 Patients with severe obesity must lose weight before they are candidates for complex body contouring procedures. All MWL patients should be counseled on expected results and expectations balanced. Patients who have obviously unrealistic goals should be deferred.
Wise pattern mastopexy with spiral flap augmentation integrates breast reshaping with UBL.3,4 Fundamental to an UBL is removal of the mid torso skin rolls and improved contour. If appropriate, the secondary component of the UBL is superior repositioning of the breast footprint and IMF.
The Wise pattern mastopexies, new IMF position, reverse abdominoplasty, lateral thoracic and superior epigastric flap harvests are planned together. The Wise pattern should be drawn with narrow and long vertical limbs to accommodate the autogenous fill. Also, the new NAC should not be placed slightly above the original IMF registration, as it will descend slightly as the IMF is raised. The preoperative markings begin with the patient sitting and marking the sternal notch with a descending vertical reference line to the xiphoid. From the mid clavicles, descending vertical reference lines are drawn through each NAC to the IMF. The ptotic NACs are elevated, and the current IMFs are sighted and drawn under each breast and then registered over the sternum. Each breast footprint is raised an appropriate distance superiorly for best esthetic appearance, and the new IMF position registered over the sternum. The ptotic NAC is pushed superiorly along the midclavicular line with the appropriately positioned nipple at the IMF level or up to several centimeters superior to about the third rib and marked on the skin and registered over the sternum. The Wise pattern keyhole encircles the nipple mark with 8–10 cm long vertical limbs that are no further apart than the width of the NAC.
With the patient standing, the excess skin of the upper abdomen is vigorously pushed superolateral. When all excess skin is gathered – the abdominal skin is tight and the umbilicus is pulled slightly cephalad – a mark is made where the gathered abdominal skin meets the new IMF position along the nipple line. With the tissues still suspended, the new parasternal and anterior axillary line attachments of the breasts are sighted and marked. The gathered tissues are dropped. The curvilinear incision line that serves both the reverse abdominoplasty and the new IMF is then drawn. This line starts at the marked parasternal breast attachment and descends to the upper abdominal marked nipple line point and then ascends to the marked point at the anterior axillary line. This line is similar to the IMF incision line of the Wise pattern, except that it includes all the redundant abdominal skin with the central breast pedicle. Obviously the reverse abdominoplasty, which removes excess skin of the epigastrium which was not corrected by prior abdominoplasty, can be performed without changing the location of the IMF. The IMFs are the upper line of excision of excess skin. The inferiorly based abdominal flaps are discontinually undermined to the costal margins. The closure ends along the newly designated IMFs, and unless there is symmastia, it does not cross the sternum. Occasionally, too much upper midline skin excess remains and then an inverted “V” of skin is excised over the xiphoid. The discontinuously undermined reverse abdominoplasty flap will be advanced and suture secured along the sixth rib (Fig. 13.1).
It is used when the back roll excess is primarily lateral to the breast and a back scar is to be avoided. Closure of the lateral and inferior donor sites achieves an upper body lift with a raised inframammary fold (IMF). (A) An extended Wise pattern de-epithelialization includes excess skin and adipose flaps lateral and inferior to the sagging and deflated breasts. (B) Full thickness flaps continuous with the central breast mound are harvested on intercostal perforating vessels for augmentation and suspension of the empty superior and deficient inferior poles of the breast. The low lying breast is undermined from about the eighth rib to the sixth rib. The upper abdominal skin is discontinuously undermined with LaRue dissectors to preserve trans-rectus abdominus perforators. (C) With care taken to preserve the breast parenchyma vascularity through the fourth and fifth intercostal, internal mammary and lateral thoracic vessels, the inferior flap extension is flipped up to augment the inferior pole and the J-shaped extension to the axilla spirals and advanced and sutured to the third rib costochondral junction to fill the superior pole and suspend the breasts. Suturing the de-epithelialized inferior flaps to the sixth costochondral cartilage in conjunction with securing the superior flap medializes and projects the combined breast and spiral flaps. (D) Closure of the Wise pattern mastopexy repositions the nipple–areola complex (NAC) and the skin flaps over the enlarged and suspended breast mound. The raised IMF is sutured along the sixth rib and the advanced back flap is sutured to the serratus muscle along the anterior axillary line from the lateral IMF to the lower axilla.
The drawing of the transverse incision lines around the mid torso extends laterally from the reverse abdominoplasty/Wise pattern mastopexy plan. For the bra line excision, the IMF and lateral Wise pattern flap markings are continued parallel and posterior, to taper together just beyond the tip of the scapula. The width between the parallel incisions is as much tissue that can be pushed and pinched together to take up all the back slack. Only in the most severe cases does the excision cross the posterior midline, because there is no lax skin over the spinal column and scarring this area disrupts the valued contoured beauty of the female mid back. Position the incision lines and gauge the tension of closure to place the closure within the posterior bra line.
In patients with less than severe back skin laxity or who refuse a mid back scar, the long posterior flap extension of the Wise pattern has been, over the past 5 years, turned superior along the mid lateral chest to end at the axilla. Often this excision is continued into an L-brachioplasty. To capture mid lateral back rolls, the flap curves inferiorly, forming a “J” shape. The entire operation can be performed in the supine position. After harvest of this mid lateral chest flap for breast augmentation, the J cut out back flap is suture advanced to the anterior serratus muscular fascia. The lateral breast is thereby bordered by tight chest wall conforming skin.27
After induction of general anesthesia, the operation starts prone with the transverse bra line back roll excision/donor site. Following infusion with epinephrine containing saline, the bra line excision is de-epithelialized using an electric dermatome set widest at 0.8 µm (32 000 of an inch). After the perimeter incisions are made, the lateral thoracic flap is raised from medial to lateral from the fascia overlying the latissimus dorsi (L-D) muscle. Several centimeters before the anterior border of the L-D, the dissection plane includes the muscle fascia and continues around the L-D to the serratus muscle fascia. As the flap lies on the OR table, the donor site is closed in two layers of absorbable barbed suture (#2 PDO and 2-0 Monoderm, Quill). Skin glue seals the closure.
The patient is turned supine. De-epithelialization of the Wise pattern, which extends inferiorly onto the abdomen, is again assisted by the electric dermatome. Completion of de-epithelialization is free hand. The lateral, superior and medial Wise pattern mastectomy type flaps are elevated superficially for 4 to 6 centimeters. The incision along the inferior margin of the extended Wise pattern is extended down to the rectus muscular fascia from the parasternal margin to the inferior incision of the lateral back flap. The lateral flap incision of the Wise pattern is continued to the upper incision of the lateral back flap. Mobilized by completion of the perimeter incisions, the most inferior portion of the lateral thoracic flap is sharply elevated from the serratus muscle until the intercostal perforators are visualized. The seventh and eighth rib perforators may be ligated. Finding these landmarks aids in preserving other perforators to the lateral thoracic flap from the third through sixth intercostals. Otherwise, the arterial pulsations between the anterior and midaxillary line can be confirmed by Doppler recordings.
The vascularity of the lateral thoracic flap is confirmed and then the inferior breast with its superiorly based epigastric extension is elevated from its descended location near the eighth rib to the sixth. Despite descended NACs, this interruption of the inferior border of the breast has had no NAC vascular compromise. That is because our breast mobilization, Wise pattern thin skin flap elevation, and positioning of the spiral flaps have not interrupted the critical transverse blood supply to the breast along the fourth and fifth intercostal septum of the breast.13 We and others have anatomically and clinically confirmed Wuringer’s anatomical vision, making the distance of NAC elevation during mastopexy essentially irrelevant as long as the mid glandular septum is preserved.14
Next, the lateral entry location for the lateral thoracic flap to its superior breast pole submammary position is started. Laterally, the lateral margin of the pectoralis muscle is located over the fourth rib and supramuscular dissection of the plane for the flap is made. Trying to avoid unnecessary trauma to the lateral thoracic artery blood supply, grasping the skin and pectoralis muscle along the anterior axillary line assists in identifying this plane. In addition an incision is made along the superior margin of the de-epithelialized new NAC site and continued to the pectoralis fascia. Then a pocket for the flap over the third rib is developed from the lateral margin of the pectoralis to the parasternal region. Finally, the medial dissection under the medial Wise pattern flap is extended superiorly to the superior pole of the breast avoiding injury to the parasternal internal mammary perforators.
A sufficiently sized pocket has been created over the pectoralis major muscle for positioning of the de-epithelialized lateral thoracic flap within the superior pole of the breast. Before the flap is placed, the descended breast is dissected from its location over the seventh and eight ribs with visual preservation of intercostal perforating vessels. The reverse abdominoplasty subcutaneous fascia is advanced to the sixth rib and serratus muscle with interrupted large braided permanent sutures. The secure IMF supports the higher breast footprint.
Then, the medially based lateral thoracic flap, which remains attached to the central breast mound, is turned cephalad along the anterior axillary line. After cutting the distal tip to check for adequate blood supply, the flap is tunneled into the superior pole pocket. The distal end dermis and fat is sutured to the parasternal region about the level of the third rib. Esthetic suture shaping is aided by the exposure created by the recent addition of the superior pole incision for exposure.
The mass of flap and breast tissue still sags laterally. To centralize the mound, the breast inferior dermal pedicle is advanced to the fifth intercostal cartilage and secured. Together with the secured lateral thoracic flap a dermal flap sling is created to provide superior to medial support. The lateral breast contour is improved by suturing the transposed flap to the lateral pectoralis major muscle. The de-epithelialized flap and breast are tailored and imbricated to optimally shape the breast. The tight closure of the lateral thoracic flap donor site from the axilla to the IMF flattens this lateral chest area to demarcate the newly created lateral breast fullness, and breast projection. The lateral chest donor site closure is continuous with the advanced and stabilized new IMF.
The excess upper abdominal de-epithelialized flap is usually flipped up and sutured to smoothly fill out the inferior pole of the breast. Dermal imbrication of the de-epithelialized breasts and the spiral flap forms the desired contour. The Wise pattern skin flaps are closed to each other and the new IMF. If the closure is too tight due to the soft tissue augmentation then further undermining of the skin flaps may be necessary. Finally, the NAC is fitted into the top of the keyhole pattern. The chest and breast incisions are covered with skin glue, dressed in light gauze, and a loosely applied surgical bra.
Usually, an L brachioplasty is performed concurrently.28 The short descending limb excision of the L may extend to the bra line closure. The full width of lateral chest excision awaits the breast closure, because the lateral chest laxity is taken in by the autogenous enlargement of the breast. Clinical examples are shown in Figs 13.2, 13.3, 13.4, 13.5, 13.6, 13.7, 13.8, 13.9, 13.10, 13.11 and 13.12.
FIG. 13.2 Before and 1 year after right anterior oblique views of an L brachioplasty combined with a J thoracoplasty modified spiral flap reshaping of the breasts with an upper body lift, reverse abdominoplasty and elevation of the IMF.
(A) Patient is 39 years old, BMI of 28.7, who lost 63 kg (139 pounds) 6 years after Roux-en-Y bypass. She had a previous abdominoplasty. As this and subsequent views (Figs 13.3–13.5) show, there is grade 3 ptosis with deflated and flat breasts, having no fill of the superior poles. Most of her back roll is immediately lateral to her breasts and will be incorporated into the J thoracoplasty for augmentation and suspension of the superior pole as indicated in the preoperative drawings on her body. The Wise pattern has 10 cm long vertical limbs to accommodate the anticipated flap augmentation. The brachioplasty markings are freehand drawn hemi ellipses along the bicipital groove, which then have measured equal distances confirmed from the elbow to the deltopectoral groove and the elbow to the end of the advancement point along the posterior border. (B) One year later, the entire breasts are higher on the chest, greatly augmented and better shaped. The raised IMFs and back skin are advanced superiorly and laterally to firmly frame the soft and well-projecting breasts. The arms were significantly reduced in volume and sag with a natural curved posterior border. The curving medial scar ascends through the minimally concaved axilla and takes a right angle turn below the deltopectoral groove to descend between the lateral breast and chest wall.