Anatomic sequelae of the upper back that occur with age or weight loss have been somewhat underserved in the plastic surgery literature. Zones of adherence in the upper posterior trunk create overhanging folds of skin and subcutaneous tissue, which are disturbing to the patient both functionally and cosmetically. These adherence points prove challenging in that they prevent contouring of the upper back with procedures such as traditional abdominoplasty or lower body lift. The bra line back lift provides a reliable and consistent method of addressing these issues by eliminating excess redundant skin and adiposity from the region.
Key points
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Laxity in the upper back is not corrected by the traditional lower body lift. The midline zone of adherence prevents transmission of contouring tension to the upper back, creating and sometimes accentuating prior contour deformities.
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The comprehensive upper back deformity, which includes laxity of the skin, excess adiposity, and redundant lateral breast tissue, can be corrected using the bra line back lift.
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This versatile technique can be used in massive-weight-loss patients or in individuals showing signs of redundant skin and adiposity as a result of age.
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Candidates for the procedure have graspable soft tissue laxity in the mid and lateral upper back.
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The surgical scar is well tolerated by patients and easily concealed beneath a bra or bathing suit top of the patients’ choice.
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The resection pattern extends to the anterior axillary line at the level of the inframammary fold.
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Preservation of the loose areolar tissue over the underlying muscle fascia will help minimize pain and swelling.
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A 3-layer space-obliterating suture closure method prevents seroma.
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Laxity from the neck to the lower back is addressed.
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The procedural learning curve is gentle for surgeons with experience in excisional body contouring, yielding consistent and predictable results.
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Patient acceptance of the procedure and its results has been universal.
Introduction/Overview
Several methods have been described to address the natural tissue effects that occur as a result of normal aging or fluctuations in weight. Distribution of subcutaneous fat and change/differences in skin elasticity can create effects on the skin that are cosmetically and functionally unappealing to patients. These effects are accentuated by natural zones of adherence for soft tissue in the body contour.
Anatomic sequelae in the upper back in particular have been somewhat underserved. Natural upper torso adherence zones in the posterior midline create tether points that lead to both horizontal and vertical laxity. A lampshade effect is created on the skin and soft tissue of the upper torso. These tether points hinder contouring of the upper back from procedures such as lower body lifts by preventing transmission of forces to this area ( Fig. 1 ). Contouring procedures of the lower and midtrunk, in fact, may even accentuate these deformities in some instances.
Treatment of this area must be tailored to the particular patient. Some may be candidates for standard tumescent liposuction or adjunctive liposuction procedures using laser or ultrasound. Skin in the upper back is robust, with thicker epidermis and dermis to aid in retraction following liposuction. With this, however, fat in the upper back, being thicker and fibrous, can make it relatively more resistant to traditional methods of liposuction. Because of this, many may be candidates for direct excision of this tissue.
Excisional methods of excess tissue in the past have been described with skin resection in a dermatomal pattern. This, however, tends to leave an oblique scar that is impossible to conceal in normal clothing. These scars are often disfiguring.
The authors present the bra line back lift, a consistent and reliable method of addressing these issues by completely eliminating both excess skin and subcutaneous fat from the region while correcting excess skin laxity in both normal-weight and massive-weight-loss populations.
Introduction/Overview
Several methods have been described to address the natural tissue effects that occur as a result of normal aging or fluctuations in weight. Distribution of subcutaneous fat and change/differences in skin elasticity can create effects on the skin that are cosmetically and functionally unappealing to patients. These effects are accentuated by natural zones of adherence for soft tissue in the body contour.
Anatomic sequelae in the upper back in particular have been somewhat underserved. Natural upper torso adherence zones in the posterior midline create tether points that lead to both horizontal and vertical laxity. A lampshade effect is created on the skin and soft tissue of the upper torso. These tether points hinder contouring of the upper back from procedures such as lower body lifts by preventing transmission of forces to this area ( Fig. 1 ). Contouring procedures of the lower and midtrunk, in fact, may even accentuate these deformities in some instances.
Treatment of this area must be tailored to the particular patient. Some may be candidates for standard tumescent liposuction or adjunctive liposuction procedures using laser or ultrasound. Skin in the upper back is robust, with thicker epidermis and dermis to aid in retraction following liposuction. With this, however, fat in the upper back, being thicker and fibrous, can make it relatively more resistant to traditional methods of liposuction. Because of this, many may be candidates for direct excision of this tissue.
Excisional methods of excess tissue in the past have been described with skin resection in a dermatomal pattern. This, however, tends to leave an oblique scar that is impossible to conceal in normal clothing. These scars are often disfiguring.
The authors present the bra line back lift, a consistent and reliable method of addressing these issues by completely eliminating both excess skin and subcutaneous fat from the region while correcting excess skin laxity in both normal-weight and massive-weight-loss populations.
Treatment goals and planned outcomes
The goals of the bra line back lift are to consistently and safely eliminate the skin and subcutaneous fat from the posterior upper torso while correcting excess skin laxity. The well-accepted position of the scar beneath the bra line without the need for a drain enhances patient satisfaction and minimizes postoperative complications. Patients are able to achieve an ideal contour with relatively minimal morbidity and downtime. The procedure may be combined safely with other body contouring procedures, such as reverse abdominoplasty, mastopexy, and breast reduction, in order to maximize patient outcomes.
Preoperative planning and preparation
The patients are given a comprehensive understanding of body contouring procedures and how they relate to their particular situation and deformity. Diagrams and photographs are reviewed and tailored to the patients’ particular goals and desires. The authors discuss a comprehensive approach to the area of treatment and how it will affect their long-term goals.
Routine complete blood counts, comprehensive metabolic panels, and coagulation profiles are drawn and reviewed. Patients are instructed to discontinue and nonsteroidal antiinflammatory drugs and herbal medications 2 weeks before surgery. Smoking is a relative contraindication.
Patient evaluation
Patients with concerns of upper back tissue excess are evaluated for skin quality, stretch marks, subcutaneous adiposity, and excess or hanging skin (see Fig. 1 ).
Most patients will grasp the redundant skin and excess adiposity of the upper back to demonstrate areas they would like to see improvement. In the full-length mirror, the surgeon shows the patients how much will be removed and the contour improvement that they will expect from the neck to the back. Redundant tissue is firmly grasped with bimanual palpation to demonstrate the final outcome in terms of tissue resection ( Figs. 2 and 3 ). The day of surgery, patients are encouraged to bring their most revealing bra or bathing suit top in order to plan the area of scar placement and ensure that their expectations will be met ( Fig. 4 ).
Patients are counseled on the importance of keeping the arms adducted until full tissue relaxation. Full range of motion will be permitted in 6 weeks or less.
Preoperative markings
Patients are marked in a standing position with arms at the sides. This position allows for the maximum amount of tissue to be to be safely removed. A standard photographic technique is used to record the entire lateral and upper back condition. These photographs consist of left and right lateral and oblique images as well as a posterior image with the patients’ arms down at the sides.
The boundary of the patients’ ideal scar position is marked to fall within the outlined margins of the bra or bathing suit top of choice ( Figs. 5 and 6 ). If there is not a preferred undergarment, then the ideal final incision line is determined by first identifying the level of the inframammary fold bilaterally. This mark is transcribed across the back in a horizontal fashion ( Figs. 7 and 8 ).
