Patient Evaluation

Patients with complaints of upper back tissue excess are evaluated for skin quality, stretch marks, subcutaneous adiposity and excess or hanging skin. Surgical judgement and patient wishes are used to formulate a surgical plan. Some patients are better candidates for standard tumescent liposuction, adjunctive liposuction procedures using laser or ultrasound, or direct excision in the form of a Bra Line Back Lift. This chaper will focus on excisional lifting (Fig. 16.1).

FIG. 16.1 Patients will often grasp the redundant skin and excess adiposity of the back demonstrating the areas they would like to see improved. Many patients are normal weight patients and are relatively young demonstrating a significant degree of laxity and excess adiposity.

The patient is examined in a full-length mirror where they can confirm the areas in need of correction. Redundant tissue is firmly grasped and brought together using bimanual palpation to demonstrate to the patient what the final outcome will be in terms of resected tissue. Because the incision begins at the lateral inframammary fold, we also manually gather excess tissue from the lateral breast area to demonstrate the flank improvement which is often desirable to the patient. We ask patients to bring in their most revealing bra or bathing suit top so we can discuss scar placement and ensure their expectations will be met (Fig. 16.2). We also discuss the importance of keeping the arms abducted until full tissue relaxation has occurred to make sure the patient is comfortable with the post operative requirements of the procedure. Full range of motion is permitted by week six.

FIG. 16.2 Patients are asked to bring their most revealing swimwear or bra beneath which they would like the final incision line to be placed. This garment takes many forms based on the patient’s desire and age. In younger patients the incision line can be placed beneath a string bikini.

Preoperative Markings

Markings are made in the standing position. We utilize a standard six position photographic technique to record the entire lateral and upper back condition. The six positions are left lateral, left oblique, posterior, right oblique, and right lateral. Boundaries of the patient’s ideal scar position are confirmed by marking the borders of a bra or bathing suit top of the patient’s choice. If the patient does not have a desired undergarment, the ideal final incision line placement is determined by identifying the level of the inframammary fold bilaterally and transcribing that across the back in a horizontal fashion (Fig. 16.3). When the final incision line has been determined, bimanual palpation is used to strongly gather the redundant skin and excess adiposity such that this redundancy centers the final incision line (Fig. 16.4). This gathering of tissue is performed at multiple spots across the entire line of resection and marked. These points are then connected as a continuum identifying the final area for resection. Note that the resection is the least in the midline because of the strong zone of adherence there (Fig. 16.5). It is this strong adherence along the spine that permits forces from lower body lifting from having any dramatic effect on the upper back. The resection is strongly tapered into the inframammary fold at the level of the anterior axillary line to avoid a dog ear. Realignment marks are then made across the area for resection to allow for precise realignment intraoperatively (Fig. 16.5). The markings are made with the arms at the patient’s side, allowing for the maximum amount of tissue to be gathered to achieve an optimal result.

FIG. 16.3 The bra is marked in blue. Note that the planned resection, marked in green, is outside of the inferior border of the bra. This is routinely the case, and as long as the markings are made keeping the final desired scar in mind (marked in black), the result is predictable. Note the incision line extends to the inframammary fold at the anterior axillary line.