CHAPTER 13 - Breast Surgery in the Massive Weight-Loss Patient

Abstract

After massive weight loss, obese women experience laxity of the skin proportional to the excess localized adiposity. The change in the breast is profound but unpredictable, owing to the variable gland to fat ratio, genetics, and prior pregnancies. Smaller breasts defl ate; larger breasts fl atten. For many, a singularly proud and voluptuous feature has been ruined. Further distorted by neighboring rolls of upper torso skin, these breasts conform poorly to brassieres. These women are resigned to concealing their breasts. Hence, among their many aesthetic concerns, breast reshaping is a priority. When given a choice, most weight-loss patients prefer mastopexy with autogenous tissue augmentation rather than augmentation with a silicone implant. Nevertheless, skin reduction pattern mastopexy with silicone implant augmentation for volume is commonly presented in plastic surgery meetings. When the senior author became active in post-bariatric surgery body in the late 1990s, he favored that approach, and both authors still use it when there is inadequate neighboring discard tissue available for augmentation. Mastopexy with an implant is expeditious, resulting in dramatically improved breast contour, symmetry, and position of the nipple–areolar complex (NAC). Nevertheless, it is a complicated procedure that fails to address chest deformity and suffers from deteriorating aesthetics. The many solutions suggested for preventing recurrent ptosis after mastopexy or breast reduction in the general population attests to its high frequency and diffi culty. Not only is there glandular ptosis, enhanced by the weight of the implants, but the loose skin breasts conforms poorly to implants (Fig. 13.1). The upper pole of the breast empties and the lower pole fi lls excessively, resulting in descent of the inframammary fold (IMF), an excessive distance between the IMF and the NAC, and an upward rise to the NAC. This deformity is treated with an upper body lift and repositioning of the implant (Fig. 13.1). With mild skin laxity of the mid-torso one may pre-empt this unfavorable cascade of poor aesthetics with a secure permanent suture advancement of the IMF along the inferior implant space (Fig. 13.2). When there is adequate breast volume and minimal mid-torso laxity and breast descent, we advocate a mastopexy with dermal to rib suspension and internal shaping technique similar to that proposed by Rubin et al. In addition we secure the IMF during the mastopexy. Massive weight-loss patients usually accept increased risk and operative time of autogenous fl aps for a more aesthetic, long-lasting outcome. Use of neighboring excess tissue for breast reshaping was proposed by Zook in the 1970s. He placed de-epithelialized discard epigastric fl aps beneath Pitanguy mastopexies. The inferior incision was carried around the trunk to correct undesirable rolls and bulk. Others used the Wise pattern and recruited skin folds below and lateral to the breasts to rebuild the breast. Successful use of a lateral thoracic fasciocutaneous fl ap for breast reconstruction by Holstrom has ignited considerable interest in this trans-serratus perforator fl ap for postmastectomy, cosmetic augmentation, and massive weight loss. Spiral fl ap breast reshaping with an upper body lift evolved to correct glandular ptosis (bottoming-out), poor breast projection, and inadequate lateral and superior pole fi ll with neighboring excess tissue. The descended IMF is raised. The inferior pole of the breast is supported and augmented by the superior rotation of excess epigastric skin and fat. The lateral thoracic fl ap is tunneled under the superior breast to impart upper pole and lateral breast fullness and curvature. The operation combines well with the L brachioplasty (Figs 13.3–13.5). Spiral fl ap refers to the invariable twisting and advancement under and around the breast of this compound superior epigastric and lateral thoracic fl ap. Previously presented in technical detail, the