Introduction

Breast deformities are the most challenging and variable part of the massive weight loss (MWL) patient; thus a thorough definition of the problem and an accordingly chosen technique determine the success of the surgical outcome.¹^–⁵ Breast deformities of the MWL patient differ from typically enlarged or ptotic breasts and therefore well-known techniques usually fail in this group. Significant breast volume depletion, and loss of upper pole and medial fullness resulting in the formation of flattened parenchyma against the chest wall, known as the “pancake” appearance, are the most common changes.^4,⁵ The majority of patients present with grade III ptosis and the two breasts are usually asymmetric because of disproportional volume loss. The breasts are displaced laterally in continuity with the lateral chest rolls and the nipple–areola complex is displaced medially. The skin envelope shows significant laxity and is covered by stretch marks.

The patients can present with excessive, sufficient, or insufficient breast volume.¹ Although MWL patients rarely have enlarged breasts, the deformity is treated by one of the reduction techniques. However, instead of standard reduction techniques, ligamentous system preservation combined with retightening procedures provides more satisfactory and long-lasting results. Therefore, we prefer a Würinger’s septum-based reduction technique.⁶ The second group includes patients who have droopy breasts with sufficient volume. Existing dermoglandular tissues are usually adequate to form a natural-looking breast and most of the patients benefit from one of the mastopexy techniques. Lastly, the majority of patients have saggy breasts with insufficient volume, so providing extra volume is mandatory to establish naturally projecting breasts. One option to correct this type of deformity is to combine mastopexy techniques with implant augmentation.^1,⁷ However, there are certain challenges with implant augmentation–mastopexy in MWL patients. Due to excessive skin laxity and loss of dermoglandular suspension, an unnatural appearance and recurrent ptosis are the most common problems after implant augmentation.⁷

On the other hand, most of these patients present with skin-fat excess, which requires excision and skin tightening procedures. This redundant skin excess provides excellent material for breast autoaugmentation.

Clinical Approach

MWL patients have other redundant parts on their body that deserve to be removed to achieve a satisfactory result. However, instead of discarding these parts, they can be used for autoaugmentation. Parts of the body that can be used to augment the breast are divided into two main groups. The first group includes the redundant skin and subcutaneous tissue near the breast that can be transferred on a reliable vascular base and the second group includes distant parts that can only be transferred as free flaps.

Techniques Based on Locoregional Tissue

In most MWL patients, breast deformity is accompanied by lateral skin redundancy or “side rolls” in the lateral thoracic area. This axillary extension of the breast can be used to provide autoaugmentation in patients with insufficient breast volume, using different surgical techniques.¹^–⁵ ^,8 ^,10 Rubin described a total parenchymal breast reshaping with dermal suspension mastopexy using the excess tissues around the breast mound.^2,⁵ A modified Wise pattern with lateral extension to encompass any significant lateral rolls was used. The technique was based on de-epithelialization of the entire region, then lateral and medial dermoglandular flaps were elevated securing them together with the central pedicle to the second or third rib periosteum with permanent sutures. Hurwitz et al described the use of lateral side rolls as a spiral flap to augment and reshape the breast in MWL patients.⁸ In this technique they de-epithelialized fasciocutaneous flap extensions of the Wise pattern mastopexy.

We suggested the use of lateral redundant dermoglandular tissue based on lateral intercostal artery perforators (LICAP) with some personal modifications.³ The technique evolved from our initial experience with the LICAP flap for partial breast reconstruction within a clinical algorithm based on the location of the defect and the availability of these perforators.⁹ A case report of pedicled perforator flaps for breast augmentation was subsequently published.¹⁰ We also reported our clinical experience with ICAP flaps and addressed the use of pedicled LICAP flaps in MWL patients.³ In a recent study we described the anatomical details of the perforators and the flap design.¹¹ As the side rolls extend more posteriorly to the back of the patient, perforators based on the thoracodorsal system can also be used as the main pedicle of the redundant tissue. The thoracodorsal artery perforator (TDAP) flap is another valuable tool that can be used for reshaping the breast via the autoaugmentation principle.^10,¹²

Techniques Based on Distant Tissue

Other parts of the body that need to be addressed during body contouring of the MWL patient are the abdomen, thighs, and buttocks. Contouring of all three parts is well described, with several modifications. The main concept in body reshaping is based on removal of these excess tissues. However, these skin and subcutaneous tissues can be transferred as free flaps and used for augmenting the breast in a single session. Although usage of these tissues is popular and widely used in postmastectomy breast reconstruction, there is little experience of augmenting the breast with free flaps for cosmetic purposes. The whole abdomen can be raised as two individual deep inferior epigastric perforator (DIEAP) or muscle sparing TRAM flaps to be transferred to the breast. Also, during the inner thigh lifting procedure, transverse skin islands can be prepared as gracilis musculocutaneous flaps and used for bilateral breast augmentation. Schoeller et al proposed a medial thigh lift free flap for autologous breast augmentation and presented their experience with three MWL patients.¹³ Likewise, upper gluteal excess and saggy infragluteal parts can be prepared on superior gluteal or inferior gluteal artery perforator flaps, respectively, to be used for breast augmentation of the MWL patient.

Preoperative Preparation

After routine preoperative screening tests and assessment of risk factors, the most important step during the preoperative period is to decide which excess part of the body will be used for autoaugmentation. If the patient has significant side rolls and the preoperative evaluation demonstrates that this excess tissue can provide sufficient volume for the breast, then we prefer to perform a pedicled flap on the lateral intercostal or, occasionally, thoracodorsal perforators. Due to relatively higher rates of complications in MWL patients, volume enhancement with free flaps is less preferred. When there is no lateral skin excess, bilateral abdominal free flaps either on paraumbilical perforators or as a muscle-sparing TRAM flap to be transferred to the breast, can be considered in patients carefully selected for breast augmentation. On the other hand, patients who want to get rid of redundant skin in the thigh region and also need to have an augmentation of their deflated breasts can be good candidates for free transverse musculocutaneous gracilis flap (TMG) transfer.

Mapping of the vascular anatomy of the chosen flap before the operation makes the surgery easier and shortens the operative time.¹⁴ Combining two procedures and an additional free flap transfer lengthens the operative time; hence any method used to facilitate the surgery is invaluable. Usually, perforators of the LICAP flap or TDAP flap are located with a unidirectional hand-held Doppler. Following the previously described anatomical outlines, it is relatively straightforward to find a reliable perforator on the back. However, the surface area of the abdomen is wide and the number and location of the paraumbilical perforators show great variability. Therefore more objective and reliable methods are needed for perforator mapping. Multidetector computed tomographic (MDCT) angiography and magnetic resonance angiography are extremely helpful tools to navigate the major perforators to be selected. Both techniques provide the exact coordinates of the points where the major perforator pierces the fascia referring to the umblicus.^15,¹⁶

Surgical Technique

LICAP Flap (Fig. 10.1)

The largest or “dominant” perforators are found between the 5th and 7th intercostal spaces in 84% of cases. The mean distance of these dominant perforators from the anterior border of the latissimus dorsi (LD) muscle varies between 2.77 and 3.68 cm.¹¹ The flap is designed lateral to the breast over the axilla and lateral thoracic area. The anterior border of the flap should include the junction of the inframammary fold (IMF) with the anterior axillary line to allow primary donor site closure. The width of the flap depends on skin redundancy and varies between 8 and 15 cm. The perforators are located with a Doppler and the closest and the most anterior perforator to the breast is chosen for adequate arc of rotation of the flap. The LD muscle is exposed after incision and the flap is elevated above the muscle fascia. Once the largest perforator closer to the pectoralis major muscle is found, it is freed off the surrounding tissue. The serratus anterior muscle is split and the perforator is dissected up to its exit above the rib. If a longer pedicle is required, dissection of the main pedicle can proceed within the costal groove. Once dissection of the perforator is complete, the rest of the flap is elevated easily above the muscle fascia. The inferior incision of the flap is then extended into the IMF. The breast gland is dissected and a retroglandular pocket is prepared for the flap. The mastopexy is first marked in a vertical scar mammaplasty pattern. The horizontal extent of the reduction pattern is determined during surgery, after harvesting and insetting the flap.