Key points
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Spiral flap breast reshaping is indicated with moderately sized ptotic breasts, surrounded by rolls of skin to obtain improved shaped breasts, and an upper body lift.
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Develop an obsessive marking technique for the confidence to commit full inclusion of nearby flaps to the breast and expeditious execution of the operation.
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Suture secure the raised inframammary fold.
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After raising the breast mound, flip up the epigastric flap to the inferior pole and spiral the lateral thoracic flap beneath the superior pole.
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Close the skin over an enlarged round breast mound under some tension, anticipating evolution into a natural breast shape.
Patient selection
After massive weight loss (MWL), breasts lose volume and projection. Both the nipple–areola complexes (NAC) and the mounds descend. Varying with the original size, fat content and shape, cherished feminine contours and softness evolve into flat, pancake shaped, floppy and firm appendages. The empty superior poles extend laterally to unattractive flattening of the anterior axillary folds. Surrounding the breasts are mid torso circumferential rolls of skin that may cascade from scapula to hip. As these patients are concerned about both the mid torso rolls and their breasts, they welcome simultaneous correction.
Excessively large and pendulous breasts are reduced. Due to excess inelastic skin, a Wise reduction pattern with an appropriate nipple pedicle is chosen. Secure suture elevation of the lateral portion of the inframammary fold (IMF) minimizes descent and bottoming out of the breasts. For breasts that may benefit from only moderate degree of augmentation, a superior flap suspension mastopexy with lateral chest wall flap augmentation can be used. When the breasts need considerable augmentation and nearby tissue is sparse, then silicone implants, usually with a mastopexy and suture fixation of the new IMF are offered.
Patients with moderate sized breasts are candidates for autogenous breast reshaping, when the neighboring tissue is full and redundant. In general, MWL patients accept breast implants only if there is no alternative. They are cautioned that recurrent breast ptosis and bottoming out of the implant is common. When autogenous tissue alternative of neighboring mid torso rolls is offered, these patients usually accept the more involved, lengthy and higher risk spiral flap reshaping. The patient must understand and accept the anticipated inverted ‘T’ mastopexy scars with transverse continuation along the bra line. When there is little back skin laxity and/or the patient objects to a back scar then she is offered a sickle-shaped skin flap excision that extends vertically from the IMF either to the axilla or the hip.
Indications for spiral flap reshaping of the breasts
The spiral flap reshaping of the breasts is best indicated when moderate to severe breast atrophy and ptosis is accompanied by full epigastric and lateral thoracic skin laxity and rolls. Inferior and lateral de-epithelialized axial pattern flaps are elevated in continuity with the Wise pattern mastopexy. These two flaps are based on intercostal perforators. The surgeon needs to understand and respect the dominant blood supply of the breast through a transversely oriented axial pattern blood supply along the third to fifth intercostal vessels. With prior breast reduction surgery the blood supply to the central breast is uncertain.
Breast reshaping is part of an upper body lift, which consists of the transverse removal of mid torso rolls, a reverse abdominoplasty, and suture repositioning of the IMF. The skin laxity and descent of the IMF progressively increases from medial to lateral. There is no redundancy of torso skin where it is broadly adherent over the sternum and spine. Accordingly, my upper body lift (UBL) rarely crosses the midlines. The relatively small amount of excess mid line epigastric skin is taken out by lateral displacement under the medial inframammary incisions. Residual rolls are taken out by secondary skin excisions, or if disturbing to the patient by secondary inverted V midline skin excisions crossing the midline. However, these midline scars are visible in low cut styles and tend to hypertrophy. In unusual cases of considerable mid epigastric skin, and/or symmastia, or mid back rolls, the UBL should continued across the midlines. Contraindications to spiral flap breast reshaping are inadequate redundant torso soft tissue bulk, unwillingness to accept the wound healing risks and smokers.
Operative technique
Pre-operative preparation
The patient is preferably marked the evening before surgery, avoiding the imperative to rush the markings for the waiting operating room team. The patient has the opportunity to review the markings and ask further questions the next day. Also, the patient is chilled due to the exposure which would leads to pre-operative hypothermia. By using permanent markers, the patient can shower with antibacterial soap the morning of surgery. The UBL and breast reshaping is usually performed after the lower body lift and abdominoplasty. When a single staged total body lift is performed, the UBL and breast reshaping are completed towards the end. Likewise for a multistage plan, the upper lift and breast reshaping along with a brachioplasty constitutes the second stage. As such, one of the objectives of the UBL is to complete treatment of the mid torso laxity not corrected by the first stage. Otherwise the lower abdominoplasty and body lift will have to complete the mid torso correction following the UBL. One indication for that reverse order would be if the patient desires maximum recruitment of limited mid torso tissue for the breast augmentation.
The markings and operation to be described are for a rather typical second stage procedure in a 47-year-old, 5′6″ woman, 2 years after losing 220 pounds from an open gastric bypass. Her high weight was 427 pounds and she presented at a stable 205 pounds. She is a full time manufacturing employee and walks several miles daily. Her first stage was a lower body lift, abdominoplasty and bilateral vertical thighplasties with ultrasonic assisted lipoplasty (UAL) (see Figure 17.3 ) The second stage consisted of an UBL, spiral flaps, brachioplasties and revision of her medial thighplasties (see Figure 17.3 ).
Marking begins by positioning the breast, NACs and IMFs, followed by the reverse abdominoplasty and back roll excision. Finally, the L brachioplasty is configured; however, the short chest limb of the L is drawn but the actual width of excision cannot be determined until the autogenous breast augmentation is completed ( Figure 17.3 ). The patient sits for the breast and arm, and stands for the upper body markings. The sternal notch and descending anterior midline is marked to the xyphoid. Seven centimeters to either side along the clavicle the mid breast meridians are drawn through the nipple to the chest wall inferior to the IMF. These markings assist in observing for deviations of the NAC or the breast from the ideal breast meridian and to adjust the superior relocation of the NAC. Short transverse lines are drawn along the IMFs and registered on at the same level on the sternum.
Low lying breasts, as confirmed by observation and patient acknowledgment, are pushed several centimeters cephalad until the proper position is attained. The new IMF is registered over the sternum, which tends to be about 3 cm cephalad to the first markings. The new nipple position is marked at or several centimeters higher than the IMF depending a variety of artistic considerations. In general the greater the volume of autogenous augmentation, the less upward positioning of the nipple, because the larger the new breast the greater the tendency towards descending into the lower pole and causing a high riding nipple. The new nipple position is then transposed from the sternal registry to cephalad of the current nipple along the breast meridian line. The differences between the meridians and the two new nipple positions are reconciled. The distances from the sternal notch to the current and future nipples are measured with care taken to avoid excessively long or short distances.
The superior border of each NAC is marked 2 cm cephalad and from that point an inverted V pattern is drawn about 14 cm long and tangential to the medial and lateral edges of each NAC. Again from the superior border of each new NAC a circle roughly 16 cm in diameter is drawn that meets roughly 4.5 cm inferior along the vertical lines. At roughly 75 degree angles transverse lines are drawn towards the sternum and mid axillary line.
Finally, the long inferior line of the Wise pattern includes the excess upper abdominal skin and fat. The surgeon pushes the entire breast mount with the ptotic lower pole cephalad until all the residual laxity of anterior skin is corrected (the umbilicus starts to move cephalad). While holding that tissue upward, a mark is made along the breast meridian that is on line with the new IMF registry over the sternum. Except in extreme cases of midline epigastric skin laxity or near synmastia, the medial inferior incision line rises from that mark along the breast meridian superiorly to meet the transverse superior medial Wise pattern line at about the sixth rib costal cartilage. The lateral line extension from the breast meridian is made where upward pushing of the skin corrects the anterolateral abdominal skin excess up to the new IMF registered over the sternum. Laterally the inferior and superior Wise pattern lines continue immediately lateral to the breast towards the inferior tip of the scapula, to include all the excess skin of the mid back rolls. The operation starts with the patient prone with the arms roughly at right angles on arms boards. Pre incision infiltration of saline containing 1 mg of epinephrine and 30 mL of 1% lidocaine per liter is customarily done.
Technique
The removal of the back roll by harvest of both lateral thoracic donor flaps (LTF) is begun with de-epithelialization using an electric dermatome set at 32/1000 of an inch. Retained islands of epithelium are removed. The two flaps may be raised simultaneously with the superior and inferior perimeter incisions from the tapered end near the tip of the scapula to the lateral boarder of the latissimus dorsi (LD) muscle. The incisions are made through the skin and subcutaneous tissue to the muscular fascia and then the donor site is undermined for several centimeters. The fasiocutaneous flap is elevated from posterior to lateral over the obliquely oriented coarse fiber LD muscle to just past its lateral border ( Figure 17.1A ). The laterally based triangular flap lies on the operating room table as the donor site is closed in two layers of a running large braided absorbable suture followed by an intracuticular closure. After the LTFs are wrapped in sterile towels, the patient is turned supine.
