Enhancing Breast Contours After Major Weight Loss: An Observational Study on the Dilemma of Implant Use

Abstract

Background:

Breast reshaping is a common request after massive weight loss, yet implant use in this population remains controversial due to higher complication risks and limited comparative data on implant types.

Methods:

This retrospective study, conducted from January 2016 to December 2022 at a public hospital, included adult female patients who underwent breast reshaping with implants. Exclusion criteria were weight loss through diet/exercise alone, a history of breast cancer, poorly managed comorbidities, and significant psychiatric disorders. The procedures were performed by a consistent surgical team, with implant selection tailored to each patient based on preoperative assessments of breast ptosis and individual expectations. Data analysis included patient demographics, surgical specifics, and postoperative complications.

Results:

Among the 56 patients studied, 38 received polyurethane implants and 18 received textured implants. The study found no significant differences between these groups regarding age, initial weight, body mass index, weight loss, return to normal activities, patient satisfaction, implant positioning, or complication rates. The overall complication rate was 37.5%, with no significant variation between the 2 implant types.

Conclusions:

The study underscores the challenges of achieving optimal results in post–massive weight loss breast reshaping due to unique deformities and a higher risk of complications. Despite ongoing debate over the ideal implant type, this research indicated no clear superiority between polyurethane and textured implants. Future research directions should explore newer ultra-light implants and compare implant-based techniques with autologous tissue approaches to further refine outcomes in this patient population.

Takeaways

Question: Which breast implant type ensures safe and satisfactory outcomes in women after massive weight loss?

Findings: In this retrospective cohort study of 56 massive weight loss patients, 38 received polyurethane implants, and 18, textured implants. No significant differences were observed between groups regarding recovery, complications (overall 37.5%), or satisfaction.

Meaning: In postbariatric breast reshaping, the similar clinical outcomes observed with both polyurethane and textured implants suggest that the high complication rates are more likely attributable to the characteristics of this patient population, rather than to the implant surface type itself.

INTRODUCTION

Body reshaping surgery is becoming even more common due to the growing number of bariatric surgery cases among industrialized and developing countries. The role of plastic surgery in formerly obese patients has already been investigated and described by several authors, who have highlighted the importance of body reshaping interventions for psychosocial reasons (such as physical appearance, relationships, career) as well as physiological-functional aspects (including musculoskeletal health, sexual dysfunction, dermatologic conditions, and respiratory problems). Furthermore, the patient’s desire to look better might support healthy eating habits and weight maintenance, leading to significant improvements in quality of life for those undergoing body contouring after massive weight loss (MWL).¹

The abdomen is often perceived as the most troublesome area, with the breast being the second most concerning body part that may require surgical reshaping.² Consequently, an increasing number of patients who have experienced MWL are seeking information and considering treatments to enhance the appearance of their breasts, often with very high expectations for the outcome and little understanding of the procedure’s risks.³

The use of mammary implants is controversial in MWL patients, and there is a significant lack of literature on this topic, with very few prior studies available.^4,5 Our research aimed to compare different types of breast implants used in MWL patients undergoing breast surgery and to analyze the outcomes and complications of these interventions.

MATERIALS AND METHODS

A retrospective analysis of all the breast reshaping procedures performed at our public hospital from January 2016 to December 2022 was conducted. All adult female patients who underwent bariatric surgery, subsequent weight loss, and mammary reshaping surgery with prostheses were considered. Before surgery, all our patients underwent a nutritional and endocrinologic evaluation to ensure that they were not malnourished and that their preoperative weight was stable. These procedures were performed by a general surgical team with experience in bariatric surgery. Only patients with a stable weight for at least 6 months underwent mammary reshaping. Exclusion criteria were weight loss achieved solely through diet and exercise, a history of breast cancer, comorbidities poorly controlled by therapy, and major psychiatric disorders. After completing the bariatric surgery course, patients were followed up at least once in our clinic. During the visit, we assessed the degree of breast ptosis, considering the position of the areola–nipple complex, the descent of the parenchyma, and the possible presence of breast asymmetry. The Pittsburgh Rating Scale was used for a better classification. During the visit, preoperative photographs were taken by an assistant surgeon. The pathology and the appropriate surgical procedure for its correction were explained to patients in detail, paying particular attention to wishes regarding the final breast volume. Patients were also invited to wear prosthesis testers inside a bra cup and indicate the situation in which they felt most comfortable. The patient then signed the informed consent, which includes information regarding the procedure involving prostheses and the associated risks (including breast implant–associated anaplastic large cell lymphoma). Patients were also asked to provide consent to the processing of personal data.

The week before surgery, all patients were examined by a senior anesthesiologist, who established the patient’s American Society of Anesthesiologists physical status classification and established the need for thromboembolic and intraoperative antibiotic prophylaxis. In our antibiotic prophylaxis protocol, we used first-generation cephalosporins (clindamycin or macrolides when there is a history of penicillin allergy) 30 minutes before surgery and every 24 hours for the following 6 days. For thromboprophylaxis, patients routinely wore anti-embolism stockings up to 10 days postoperatively. All patients were operated on by a team consisting of the same senior surgeon and 1 or 2 assistants with comparable experience. The type and size of the prosthesis were chosen through a customized case-by-case study, based on a thorough preoperative evaluation of each patient’s breast characteristics, skin quality, degree of ptosis, and expectations. Polyurethane-coated implants were generally preferred in cases with poor skin elasticity or a higher risk of implant displacement. In contrast, textured implants were selected in patients with better tissue support, particularly in combination with mastopexy procedures. The final decision was always discussed with the patient, considering both clinical indications and individual preferences. Preoperative drawings were made with the patient sitting upright about 1 hour before the operation. During surgery, dedicated sizers were used before choosing the definitive model of the implants. We used 3 different brands of prostheses. All implants were round and microtextured. The volume of the implants varied from 100 to 400 mL, and projection could be low, moderate, or high for each type. We performed 3 main types of access to achieve the breast lift and insert the implant: periareolar (round-block), vertical, and inverted-T. The positioning of the prosthesis was carried out through the packaging of a subglandular or submuscular pocket.

Subcutaneous enoxaparin 40 mg/d was administered starting on the first postoperative day and continuing until full mobilization was attained. We routinely use drains, which are kept in place until they collect less than 50–70 mL/d. Follow-up visits were usually scheduled at 7, 14, and 30 days and 3–6 months after the surgical procedure. The main source of data for the retrospective study was our clinic’s database, which is updated on a regular basis with all patient data. For more information, patients were also contacted via phone. We collected the following data: follow-up period, age, pre- and postbariatric surgery weight and body mass index (BMI), total weight loss, pregnancies, breastfeeding, menopause status, weeks to return to normal activities, and overall personal satisfaction, graded from 0 (totally unsatisfied) to 10 (enthusiastic). We recorded the implant volume and position, which can be prepectoral, subfascial, subglandular, or submuscular. We considered the following complications related to the prosthesis implants at 1, 3, and 6 months: surgical site infections, implant displacement or asymmetry, recurrent ptosis, and capsular contraction (defined as greater than Baker II). We also distinguished cases that needed an intraoperative surgical revision from minor and hardly objective complications, which caused only a slight discomfort without affecting quality of life.

The statistical software SPSS (Statistical Package for Social Studies, IBM Corp., Armonk, NY) was used to run the analyses. We used relative frequencies for categorical data and the mean and SD for continuous variables. All continuous variables were reported as mean ± SD and analyzed using the Student t test, as the normality assumption was considered acceptable according to the Kolmogorov–Smirnov test. For categorical variables, comparisons of frequency distributions were performed using the Fisher exact test. A significance level of at least 5% (P < 0.05) was established.

RESULTS

The final sample included 56 patients who underwent breast surgery, divided into 38 patients in the first group receiving polyurethane implants and 18 patients in group 2 receiving textured implants. The mean age was 41.8 years with a SD of 10.7 years; for group 1, the median age was 41.7 ± 11.8 years, and for group 2, it was 41.8 ± 7.9 years (P = 0.9669).

The mean patient initial weight was 122.7 ± 22.7 kg overall, with an initial BMI of 43.7 ± 7.5 kg/m². In group 1, the mean initial weight was 122.1 ± 19.3 kg with a mean initial BMI of 43.3 ± 6.4 kg/m², whereas in group 2, the mean initial weight was 124.1 ± 29.4 kg (P = 0.7915) with a mean initial BMI of 44.4 ± 9.7 kg/m² (P = 0.6609).

When considering presurgery weight, the mean was 69.9 ± 11.1 kg overall, 69.9 ± 10.8 kg for group 1, and 69.7 ± 12.1 kg for group 2 (P = 0.9308). Presurgery mean BMI was 24.9 ± 3.3 overall, 25.0 ± 3.3 for group 1, and 24.7 ± 3.3 for group 2 (P = 0.7744). Mean weight loss was 52.9 ± 17.7 kg overall, 52.1 ± 14.0 kg for group 1, and 54.4 ± 24.0 kg for group 2 (P = 0.7080).

The number of weeks before patients returned to normal life was analyzed, showing an overall mean of 4.1 ± 2.2 weeks; 3.9 ± 1.6 weeks for group 1 and 4.4 ± 3.0 weeks for group 2 (P = 0.5457). Mean personal satisfaction, graded from 0 to 10, was 7.6 ± 2.2 overall, 7.7 ± 2 in group 1, and 7.2 ± 2.7 in group 2 (P = 0.3713).

Implants were positioned prepectoral in 2 patients (3.6%), both in the first group (5.3%). Only in 1 case, implants were placed subfascial (1.8%) using a textured prosthesis (5.6% of group 2). The majority of implants were placed in the subglandular position, including 50 patients overall (89.3%), 34 in group 1 (89.5%), and 16 in group 2 (88.9%). Three patients received submuscular implants (5.4% overall), 2 patients in group 1 (5.3%), and 1 patient in group 2 (5.6%). Mean implant volume was 269.9 ± 49.5 mL overall, 268.6 ± 43.2 mL for group 1, and 271.6 ± 61.8 mL for group 2 (P = 0.8340).

At the time of data collection, 26 (37.5%) patients had complications, 17 (44.7%) patients in group 1, and 9 (50.0%) patients in group 2. Among the 30 patients (62.5%) who did not develop any complication, 21 (55.3%) were in group 1 and 9 (50.0%) in group 2.

The cases that required a surgical reintervention were 11 (29.0%) in group 1 and 8 (44.4%) in group 2, accounting for a total of 19 patients (33.9%). However, 27 (71.0%) patients in group 1 and 10 (55.6%) patients in group 2, representing 37 patients (66.1%), did not require surgical revision.

The complications observed were as follows: 1 case of surgical site infection (group 1); 7 cases of implant displacement or asymmetry (4 in group 1 and 3 in group 2); 10 cases of recurrent ptosis (6 in group 1 and 4 in group 2); 6 cases of capsular contracture (defined as greater than Baker grade II) (4 in group 1 and 2 in group 2); 1 case of postoperative anemia requiring transfusion (group 1); and 1 case of deep vein thrombosis of the left upper limb (group 1) requiring medical therapy. In the case of infection, the patient underwent surgical drainage, repeated pocket irrigation, and implant removal. Cases of implant displacement or asymmetry, recurrent ptosis, and capsular contracture were treated with revision surgery only when they caused significant physical or psychological discomfort to the patient. The median follow-up was 15 weeks (min–max 1–30 wk) for group 1 and 18 weeks (min–max 2–48 wk) for group 2. The results are summarized in Table 1. We divided the patients into 2 groups: the first included patients undergoing polyurethane prosthesis placement (examples in Figs. 1–4) and the second included patients undergoing the implantation of textured prostheses.

Table 1.

Summary of the Study Results

	Overall, 56 (100.0%)	Polyurethane, 38 (67.9%)	Textured, 18 (32.1%)	P
Patient age, y, mean ± SD	41.8 ± 10.7	41.7 ± 11.8	41.8 ± 7.9	0.9669
Patient initial weight, kg, mean ± SD	122.7 ± 22.7	122.1 ± 19.3	124.1 ± 29.4	0.7915
Patient presurgery weight, kg, mean ± SD	69.9 ± 11.1	69.9 ± 10.8	69.7 ± 12.1	0.9308
Weight loss, kg, mean ± SD	52.9 ± 17.7	52.1 ± 14.0	54.4 ± 24.0	0.7080
Patient initial BMI, kg/m2, mean ± SD	43.7 ± 7.5	43.3 ± 6.4	44.4 ± 9.7	0.6609
Patient presurgery BMI, kg/m2, mean ± SD	24.9 ± 3.3	25.0 ± 3.3	24.7 ± 3.3	0.7744
Time to normal activities, d, mean ± SD	4.1 ± 2.2	3.9 ± 1.6	4.4 ± 3.0	0.5457
Satisfaction	7.6 ± 2.2	7.7 ± 2	7.2 ± 2.7	0.3713
Implant position, n (%)
Prepectoral	2 (3.6)	2 (5.3)	0	0.5439
Subfascial	1 (1.8)	0	1 (5.6)
Subglandular	50 (89.3)	34 (89.5)	16 (88.9)
Submuscular	3 (5.4)	2 (5.3)	1 (5.6)
Implant volume*, mL, mean ± SD	269.9 ± 49.5	268.6 ± 43.2	271.6 ± 61.8	0.8340
Complications, n (%)
Yes	26 (37.5)	17 (44.7)	9 (50.0)	0.7789
No	30 (62.5)	21 (55.3)	9 (50.0)
Reoperations, n (%)
Yes	19 (33.9)	11 (29.0)	8 (44.4)	0.3653
No	37 (66.1)	27 (71.0)	10 (55.6)

*In cases where left and right implants had different volumes, the mean volume was considered.

Fig. 1.

Preoperative frontal view with preoperative drawings. The patient was a 39-year-old woman who lost 82 kg after vertical gastroplasty surgery. She presented with grade 2 ptosis, volume loss, and loose skin.

Fig. 4.

Postoperative lateral view.

Fig. 2.

Preoperative lateral view with preoperative drawings.

Fig. 3.

Postoperative frontal view, 3 months after mastopexy with the Lejour technique and implantation of 310-g round polyurethane prostheses.

As far as sociodemographic and anthropometric data are concerned, the 2 groups have comparable results in terms of age (P = 0.9669), initial weight (P = 0.7915), and presurgical weight (P = 0.9308). The initial BMI and the presurgical BMI were also comparable with P values of 0.6609 and 0.7744, respectively. The average weight loss was comparable between the 2 groups with a P value of 0.7080. The time required after surgery before being able to return to normal daily activities was about 4 weeks, similar in the 2 groups (P = 0.5457). The 2 groups were also comparable in terms of patient satisfaction, with an average score of 7.7 for the first group and 7.2 for the second (P = 0.3713). There were no statistically significant differences either in prosthetic positioning (P = 0.5439) or in the average volume of prosthetics chosen between the 2 groups (P = 0.8340). With regard to complications and reinterventions, the 2 groups had comparable results, with P values of 0.7789 and 0.3653, respectively.

DISCUSSION

Achieving a long-lasting, attractive outcome can be more challenging in patients with MWL compared with others. These patients present with a characteristic deformity: deflated breasts with medialized nipples and a defined axillary roll, varying degrees of ptosis due to significant breast volume loss, deflation and flattening of the breast against the chest wall, and relative skin excess compared with parenchymal volume.⁶ Changes in the skin structure, including collagen and elastin content, have been reported and are associated with a higher risk of complications after body-contouring surgery.⁷

Careful analysis of the degree of breast deformity, including its volume and shape, can help the surgeon make the correct decision. Over the past few years, several articles have been published to classify breast contour deformity and breast ptosis after bariatric weight loss.^8,9 Some authors have proposed modern clinical classifications to define options for surgical management of the ptotic breast with and without augmentation.¹⁰ Among them, the Pittsburgh Rating Scale, which evaluates mammary deformity, is probably the best known and validated.⁵

According to our experience, the main breast problems reported by an ex-obese patient are simple ptosis, ptosis with excess volume, or ptosis with loss of volume. If a volume increase is considered advisable, one of the most debated issues is the use of mammary prosthetic implants. MWL patients are not good candidates for traditional breast reshaping techniques because of the extent of the deformities that are associated with recurrent ptosis and malposition, leading to increased rates of revision procedures. On one hand, there is a request to restore the volume lost through weight loss and to give their breasts a more florid and youthful appearance. On the other hand, a foreign body has a specific weight that will tend to stretch tissues already poor in extracellular matrix and elastin, with a significant risk of scar alteration and recurrent ptosis.^8,11,12 Because of those additional complications, some authors do not recommend the use of prostheses.⁶

The topic debated worldwide among surgeons who still decide to use implants is: what is the best prosthesis for a postbariatric patient? The current literature lacks a comparison between the different types of breast implants. Our research compares 2 groups of patients: textured and polyurethane prostheses.

Data analysis shows no significant differences between polyurethane prostheses and textured prostheses. The complication P value is very high (0.7789), and the reoperation data are comparable between the groups. There is no significant information regarding whether polyurethane implants reduce or increase any complications over time compared with textured implants in this particular type of patient. The lack of significant data cannot be attributed to confounding factors (such as weight, age of the patient, or volume of the prostheses) because the characteristics of the 2 groups are homogeneous. The mean satisfaction is also similar (7.7 of 10 for polyurethane patients versus 7.2 for textured patients). Another finding that emerged was the high rate of surgical complications (37.5%), similar among the 2 groups and close to the results of other authors.^13,14 The limitations of our study concern the small sample size and the absence of new ultra-light implants (which the authors have started to use, but without adequate long-term follow-up).

Another limitation of the study is the lack of age group analysis in relation to complications. Although patient age was collected and reported, it was not included in the outcome assessment to avoid confounding the primary objective of comparing 2 treatment protocols. Additionally, breast measurements before and after surgery were not discussed, as the focus of the study was on comparing outcomes and complication rates. Furthermore, the study was not structured to allow for an in-depth epidemiological analysis of the patient population. Potentially relevant factors influencing complications—such as underlying medical conditions, smoking status, and alcohol consumption—were not included. Future studies should include a larger sample size, incorporate age group stratification, analyze breast measures, and consider relevant epidemiological factors to better assess their correlation with complication rates and surgical outcomes.

Considering the limiting factors, we can state that mastopexy with prostheses in postbariatric patients exposes them to a high risk of surgical complications and a high rate of reoperation. This risk, unfortunately, cannot be avoided with an “ideal” implant at present; in the modern era, where social media provides easy access to “prêt-à-porter” information, it is critical to communicate honestly with patients about expected results and potential complications to prevent miscommunication and disappointment. Providing them a reliable long-term follow-up is also essential to avoid worse results.¹⁵ In future research, it will be interesting to analyze differences in outcomes, complications, and satisfaction of patients after mastopexy with a prosthesis and compare them with mastopexy using autologous tissue.

CONCLUSIONS

Individual assessment of breast conditions, skin quality, and patient expectations is crucial to achieve optimal results and reduce the rate of complications in women after MWL. According to the research data, there were no differences in the results between patients treated with polyurethane and textured implants. Accordingly, there is currently no ideal implant for postbariatric individuals. Future studies should explore alternative options, including newer generations of implants such as ultra-light prostheses, to assess whether they may offer additional benefits in the care of postbariatric patients.

DISCLOSURE

The authors have no financial interest to declare in relation to the content of this article.

ETHICAL APPROVAL

All procedures performed in studies involving human participants were conducted in accordance with the ethical standards of the institutional and national research committees and with the 1964 Declaration of Helsinki and its later amendments or comparable ethical standards. This article does not contain any studies with human participants or animals performed by any of the authors.