Reshaping the Postbariatric Breast: A Single-center Experience With the Dermal Suspension Parenchymal Reshaping Mastopexy Technique

Abstract

Background:

Massive weight loss frequently results in significant skin laxity, particularly in the chest and breast region, presenting reconstructive challenges. Traditional mastopexy techniques often fail to address the complex deformities seen in postbariatric patients. The dermal suspension parenchymal reshaping (DSPR) mastopexy offers a novel approach to restoring breast shape and contour in this population. This study aims to evaluate the short- and long-term outcomes of DSPR mastopexy.

Methods:

We conducted a retrospective cohort study of female patients who underwent DSPR mastopexy at Hadassah Medical Center between 2018 and 2024. Eligible patients had experienced massive weight loss via bariatric surgery or lifestyle changes. Data were collected on demographics, comorbidities, surgical parameters, patient-reported outcome measures, complications, and long-term outcomes.

Results:

Eight patients underwent DSPR mastopexy, including 1 unilateral case, for a total of 15 operative breasts. The median age was 32.2 years (interquartile range 27.7–37.6 y). Half of the patients reported active or recent nicotine use, ceasing smoking only perioperatively. One minor complication, a seroma in 1 of 15 breasts (6.7%), was managed conservatively. No other complications were recorded. The postoperative BREAST-Q questionnaire demonstrated high patient satisfaction in multiple domains. At a median follow-up of 5 years, all patients maintained favorable aesthetic outcomes with no revision surgery.

Conclusions:

The DSPR mastopexy technique is a safe and effective method for postbariatric breast reshaping, with durable aesthetic outcomes and high postoperative BREAST-Q satisfaction. Even among recent smokers, no complications occurred. Our findings support broader adoption of the DSPR mastopexy in selected patients.

Takeaways

Question: What problem does the dermal suspension parenchymal reshaping (DSPR) mastopexy technique address in postbariatric patients?

Findings: This retrospective single-center study evaluated 8 female patients (15 breasts) who underwent DSPR mastopexy after massive weight loss. All achieved long-term aesthetic improvement without major complications during a median 5-year follow-up. One minor seroma (6.7%) was reported. Half of the patients were recent or active smokers, yet no wound healing complications occurred. The DSPR technique provided durable upper-pole fullness, effective nipple repositioning, and improved contour restoration.

Meaning: DSPR mastopexy is a safe and effective approach for reshaping the postbariatric breast, showing excellent long-term outcomes even in higher risk surgical candidates.

INTRODUCTION

Obesity is a global phenomenon affecting populations across countries and continents. As of 2022, 1 in 8 people worldwide were living with obesity.¹ To combat obesity and mitigate its sometimes fatal complications, various weight loss strategies have been developed.^2–4 Traditionally, dietary modifications and lifestyle changes were the primary interventions. Yet, during the past several decades, surgical solutions have become increasingly common.^5,6

Bariatric surgery was first introduced in the 1950s and has since evolved significantly, particularly with the advent of laparoscopic techniques in the 1980s.⁷ Regardless of the method—surgery, pharmacotherapy, or lifestyle change—the end goal remains weight loss. However, following significant weight loss—especially when rapid or massive—patients often develop redundant and lax skin, which may affect multiple body regions. These include the face, neck, chest, arms, abdomen, upper and lower back, buttocks, and thighs.⁸

Excess skin in the chest and breast area poses unique reconstructive challenges, particularly in women.^9,10 Traditional classifications of breast ptosis, such as the Regnault and Kirwan systems, primarily describe aging or postpartum breasts and are less applicable to the deformities observed after massive weight loss (MWL).¹¹ In patients with MWL, breast deformities often include severe skin laxity, volume deflation, medial displacement of the nipple–areola complex (NAC), and prominent lateral chest wall rolls.^9,10,12,13

Various mastopexy techniques exist to address breast ptosis and skin excess.^14–16 However, the traditional methods were developed primarily for gravitational ptosis in aging breasts. They are often inadequate in addressing the complex deformities associated with MWL and may yield only short-lived aesthetic results due to reliance on inelastic skin for support.^12,17,18

Rubin and Khachi¹⁹ described the dermal suspension parenchymal reshaping (DSPR) mastopexy technique for treating breast deformity following MWL. The technique reshapes the deflated, ptotic breast using all available tissue, including lateral breast rolls, as well as NAC repositioning and restoring upper-pole fullness. Despite its clinical utility, the long-term outcomes and complication profiles of the DSPR mastopexy technique remain underreported in the literature. Therefore, we aim to describe our experience with the DSPR mastopexy technique in a public, university-affiliated teaching hospital setting. Specifically, we focus on standardized patient selection, long-term aesthetic stability during a 5-year follow-up period, patient-reported outcome measures (PROMs) assessed using the BREAST-Q questionnaire, and the safety profile in a high-risk cohort that includes active smokers.

MATERIALS AND METHODS

Ethical Considerations

The study was approved by the Hadassah Medical Center institutional review board (HMO 0109-25). The article was written and edited in accordance with the STROBE (strengthening the reporting of observational studies in epidemiology) statement guidelines.²⁰

Study Design and Setting

This retrospective cohort study analyzed data from patients who underwent mastopexy using the DSPR technique at Hadassah Medical Center between August 2018 and December 2024.

Patient Selection

Eligible patients included individuals who had undergone MWL, defined as a reduction of at least 50% of excess weight,²¹ either through bariatric surgery, such as laparoscopic adjustable gastric banding, laparoscopic sleeve gastrectomy, laparoscopic mini-gastric bypass, or laparoscopic Roux-en-Y gastric bypass, or through sustained lifestyle modifications involving diet and physical activity. Weight stability was defined as a fluctuation in body weight of less than 5% for a minimum of 12 months before body contouring surgery, exceeding the minimum 3–6 months stability period often recommended in the literature.²²

All DSPR procedures were performed in a public healthcare setting by a senior plastic surgeon in collaboration with a plastic surgery resident (D.A. and S.M.). Some patients underwent DSPR mastopexy in combination with upper body lift (UBL) or brachioplasty procedures, whereas the majority underwent mastopexy alone using the DSPR technique.

All patients underwent a standardized preoperative evaluation in accordance with Israeli national guidelines for breast surgery (guidelines to be referenced). This included a complete blood count, serum biochemistry (electrolytes, renal and liver function tests, albumin), coagulation profile, electrocardiogram, chest x-ray, and breast imaging. Upon completion of this workup, each patient was reassessed by their plastic surgeon and subsequently evaluated by an anesthesiologist in the preoperative clinic.

Surgical Technique

Our surgical method followed the DSPR technique, a procedure pioneered by Rubin and Khachi,¹⁹ with intraoperative modifications tailored to the patient’s anatomy and the intended aesthetic or reconstructive goals. Preoperative markings are performed with the patient in a standing position (Fig. 1). The midline is drawn from the suprasternal notch to the umbilicus, and the inframammary folds (IMFs) are outlined. The breast meridian is identified by bisecting each breast into equal halves. The new NAC position is determined using 3 anatomical references: the mid-humeral point, a vertical measurement of 19–23 cm from the sternal notch, and the projection of the IMF onto the breast meridian, in accordance with Pitanguy guidelines. The upper limit of the areola is marked 2 cm above the new nipple position. A Wise pattern is then designed, with 6-cm vertical limbs connected laterally to encompass redundant lateral breast and axillary roll tissue intended for use in autologous augmentation. In cases of combined UBL, the lateral limb is extended posteriorly to incorporate the back-lift markings. In cases of combined brachioplasty, the lateral limb is extended superiorly to incorporate the L-shaped lateral chest extension of the brachioplasty markings.

Fig. 1.

Standing markings delineate the midline, IMFs, and breast meridian; The NAC level is set per Pitanguy landmarks, and a Wise pattern is planned with lateral extension to recruit axillary/lateral roll tissue as needed.

Surgery is performed under general anesthesia with endotracheal intubation. The patient is positioned supine with arms abducted to 90 degrees. A solution of normal saline with adrenaline at a concentration of 1:200,000 is infiltrated beneath the surgical markings. The new areola is marked with a 42-mm cookie cutter. De-epithelialization is carried out over the entire Wise-pattern area, sparing only the region corresponding to the future areola. Three dermoparenchymal flaps—superior, lateral, and medial—are elevated, each based medio-centrally. A skin flap is raised in the upper pole of the breast, extending cephalad from the superior limb of the Wise pattern toward the clavicle in a suprafascial plane. The NAC is preserved on a centrally based pedicle. The patient is then seated upright to assess symmetry and optimize flap positioning. The superior dermoparenchymal flap is anchored to the periosteum of the second rib along the breast meridian using a 0 nonabsorbable nylon suture (Fig. 2A). The NAC position is evaluated and adjusted as necessary to ensure appropriate vertical alignment. Next, the lateral flap is suspended to the third rib, followed by suspension of the medial flap to the fourth or fifth rib, both using the same suture technique (Figs. 2, 3A). All suspension steps are performed bilaterally in a synchronized manner to ensure optimal symmetry and to allow for immediate intraoperative correction. Additional suspension sutures may be placed to reinforce fixation of the breast tissue. At this stage, the breast mound is elevated but not yet fully contoured. Therefore, dermal plication is performed to shape the parenchyma. Inverted 2-0 Vicryl sutures are used to plicate the dermis of the lateral flap to the central flap, followed by similar plication of the medial flap to the central flap. Additional plication is performed at the inferior pole to enhance breast projection and reduce nipple-to-IMF distance. A second layer of continuous fine-tuning sutures may be added for refinement and symmetry. Following shaping, the lateral dermoparenchymal flap is anchored to the chest wall to further contour the lateral breast and secure the NAC in position (Fig. 3B). The skin envelope is then redraped over the reshaped parenchyma and temporarily approximated using skin staples. (See Video [online], which displays the final stage of the surgical procedure, in which the skin envelope is redraped over the reshaped parenchyma.) The final NAC position is evaluated again; if tethering or misalignment is observed, a dermal release incision around the NAC is made to achieve the desired location. Once symmetry and aesthetic goals are confirmed, the patient is returned to the supine position. A Jackson-Pratt drain is inserted laterally into each breast and secured with 3-0 nonabsorbable Ethilon sutures. Closure is performed in 3 layers: 2-0 absorbable Vicryl for the superficial fascia, 3-0 Monocryl for the subdermal layer, and 3-0 V-Loc sutures for intradermal closure. Finally, the patient is dressed with a supportive postoperative bra designed for breast procedures.

Fig. 2.

Key intraoperative steps of the dermal suspension parenchymal reshaping mastopexy technique. After Wise-pattern de-epithelialization, the dermoparenchymal flaps are elevated on a central pedicle and fixed to the ribs—superiorly to the second (A) and laterally to the third (B).

Fig. 3.

Key intraoperative steps of the dermal suspension parenchymal reshaping mastopexy technique. After Wise-pattern de-epithelialization, the dermoparenchymal flaps are elevated on a central pedicle and fixed to the ribs: medial to the fourth–fifth (A) to achieve durable autoaugmentation and upper-pole support. Dermal plication of the lateral and medial flaps to the central mound is then performed, with additional inferior-pole plication to increase projection and reduce the nipple–IMF distance (B).

Video 1. A video capturing the final stage of the surgical procedure, in which the skin envelope is redraped over the reshaped parenchyma.

Download video file ^{(1.2MB, mp4)}

Postoperatively, patients were hospitalized for a period ranging from 1 to 5 days following surgery. During hospitalization, they received intravenous prophylactic antibiotics, analgesics, antiemetics, and intravenous tranexamic acid, provided there were no contraindications based on hematologic history. Pulmonary toileting, including incentive spirometry with Tri-Flow, was initiated on postoperative day 1 and continued throughout the hospitalization period. The breasts and NACs were clinically assessed at least twice daily, with increased frequency as needed based on clinical findings. Patients were discharged home with Jackson-Pratt drains in place. The first postoperative follow-up visit was scheduled for 2 weeks after surgery. Drains were removed once the output was less than 25 mL per drain for 2 consecutive days.

Patient-reported Outcome Measures

Postoperative PROMs were assessed using the BREAST-Q questionnaire, reduction/mastopexy module. Patients were invited to complete the postoperative module at their most recent follow-up or remotely. Five of 8 (62.5%) patients returned complete questionnaires, and these responses were included in the PROM analysis. Domain scores were calculated according to the BREAST-Q scoring manual and converted to a 0–100 scale, where higher scores indicate greater satisfaction or better health-related quality of life. Item-level responses for the “satisfaction with nipples” domain were reported as individual questions, as presented in Table 1.

Table 1.

Detailed Postoperative BREAST-Q Questionnaire Outcomes for Each Domain

Domain	Mean ± SD (n = 5)
Psychosocial well-being	97.60 ± 5.37
Sexual well-being	98.00 ± 4.47
Physical well-being	62.40 ± 35.23
Satisfaction with breasts	92.20 ± 17.44
Satisfaction with nipples*
Position	95.00 ± 11.18
Alignment	90.00 ± 13.69
Shape	80.00 ± 32.60
Appearance	80.00 ± 32.60
Sensation	55.00 ± 27.39
Satisfaction with outcome	78.20 ± 13.42
Satisfaction with information	95.00 ± 11.18
Satisfaction with surgeon	100.00 ± 0.0
Satisfaction with medical team	100.00 ± 0.0
Satisfaction with office staff	100.00 ± 0.0

^*Each row is derived from the individual questions as provided by the BREAST-Q questionnaire domain “Satisfaction with nipples.”

Statistical Analysis

Categorical variables, including history of nicotine use, diabetes mellitus, hypertension, hyperlipidemia, coagulopathy, and parity, are presented as frequencies and percentages. Continuous variables, including age, body mass index (BMI) before bariatric surgery, BMI before DSPR mastopexy, surgical time, length of hospitalization, and postoperative hemoglobin levels, are reported as medians with interquartile ranges (IQRs). BREAST-Q domain scores are presented as mean ± SD. In addition, we analyzed complications, as assessed based on clinical examination, including hematoma, seroma, infection, partial or complete NAC necrosis, dehiscence, flap necrosis, and fat necrosis.

RESULTS

Patient Demographics and Preoperative Characteristics

A total of 8 female patients, accounting for 15 breasts (including 1 unilateral procedure), underwent DSPR mastopexy at Hadassah Medical Center between 2018 and 2024. The median age at the time of mastopexy was 32.2 years (IQR 27.7–37.6 y). All patients had a history of MWL, with a median BMI before intervention of 46.8 kg/m² (IQR 45.2–50.9 kg/m²). The median minimal BMI achieved before the DSPR mastopexy was 25.9 kg/m² (IQR 23.4–28.7 kg/m²) with a median weight stability duration of 18 (IQR 12–24) months before surgery. Comorbidities were rare in this cohort: no patients had type 2 diabetes mellitus, hypertension, or dyslipidemia. One (12.5%) patient reported selective serotonin reuptake inhibitor use. Additionally, 3 (37.5%) patients reported active nicotine use in the preoperative period, and 1 (12.5%) was a former smoker. None of the patients reported any history of cannabis use (Table 2).

Table 2.

Detailed Patient Follow-up Duration

Patient Number	Procedure	Follow-up Duration, mo
1	DSPR mastopexy + brachioplasty	86
2	DSPR mastopexy	68
3	DSPR mastopexy	68
4	DSPR mastopexy	67.5
5	DSPR mastopexy + UBL	57
6	DSPR mastopexy + UBL	17
7	DSPR mastopexy	24.5
8	DSPR mastopexy	6
Average		49.25
Median		62.25
IQR		18.875–68.875

Surgical Details and Complications

Surgical procedures included DSPR mastopexy alone in 5 (62.5%) patients, DSPR mastopexy combined with UBL in 2 (25%) patients, and DSPR mastopexy combined with brachioplasty in 1 (12.5%) patient. Symmetry was achieved intraoperatively and maintained during follow-up. All patients achieved satisfactory aesthetic results, including NAC repositioning and clinically improved upper-pole contour, with no need for revision surgery (Figs. 4, 5). The median follow-up duration was 5.2 years (IQR 1.6–5.7 y). Individual follow-up durations for each case are provided in Table 2.

Fig. 4.

A 30-year-old patient after MWL presenting with grade III ptosis underwent dermal suspension and parenchymal reshaping mastopexy. Preoperative (A, C, E) and 12-month postoperative (B, D, F) views demonstrate durable NAC elevation, maintained upper-pole support, balanced breast contour, well-maturing scars, and no need for revision.

Fig. 5.

A 38-year-old woman after dermal suspension and parenchymal reshaping mastopexy performed concurrently with a UBL. Preoperative (A, C, E) and 12-month postoperative (B, D, F) views show correction of grade III ptosis with durable upper-pole support, maintained projection, and balanced breast contour. Scars are maturing appropriately, and no revision was required.

The median surgical time was 513 minutes (IQR 446–555 min), with all patients hospitalized postoperatively for a median of 5 days (IQR 3–6 d). No major complications—hematoma, seroma requiring aspiration, infection, NAC necrosis, skin necrosis, fat necrosis, or reoperation—were reported. One minor complication—a seroma—was reported in 1 of the 15 operative breasts (6.7%). This occurred in a patient who underwent DSPR mastopexy combined with a UBL. The complication resolved with conservative treatment in the outpatient setting.

Patient-reported Outcome Measures

Five of 8 (62.5%) patients completed the postoperative BREAST-Q questionnaire and demonstrated high levels of postoperative satisfaction across most domains (Table 1). Mean scores showed high psychosocial well-being (97.6 ± 5.4) and sexual well-being (98.0 ± 4.5). Satisfaction with breasts was high, with a mean score of 92.2 ± 17.4, whereas the overall satisfaction with the surgical outcome was 78.20 ± 13.42. Within the “satisfaction with nipples” domain, patients reported high scores for position (95.00 ± 11.18) and alignment (90.00 ± 13.69), whereas scores were comparatively lower for sensation (55.00 ± 27.39). Physical well-being of the chest area yielded a mean score of 62.40 ± 35.23. Additionally, patients reported maximum satisfaction scores (100.00 ± 0.0) regarding their interactions with the surgeon, the medical team, and the office staff.

DISCUSSION

The DSPR mastopexy technique demonstrated excellent outcomes in this cohort, with no major short- or long-term complications observed during a median follow-up period of 5 years. Notably, even minor complications were rare, with only 1 case of a seroma, which resolved with conservative management in an outpatient setting. This low complication rate is particularly noteworthy given the high prevalence of smoking, the complexity of the procedure, and the challenging anatomical characteristics of postbariatric patients.

The DSPR mastopexy technique, developed by Rubin and Khachi,¹⁹ is a technically demanding procedure that integrates suspension and redistribution of the breast parenchyma using dermoparenchymal flaps. It requires precise anatomical planning and intraoperative adaptability, especially in cases with extensive lateral tissue and significant ptosis. Despite these technical challenges, our results underscore the method’s reliability and reproducibility when performed by experienced surgeons. This technique remains relatively rare and underreported in the literature. Although various mastopexy techniques have been described for the postbariatric population, few address the unique deformities seen after MWL as comprehensively as DSPR.²³

Our study contributes to the limited but growing body of evidence supporting the use of DSPR by adding extended follow-up and reporting both short- and long-term outcomes. Although several studies have reported perioperative safety and early results, multiyear follow-up and durability metrics are less consistently reported in the DSPR literature.^10,24 Okada et al,²⁴ in a study of 14 patients, demonstrated the technique’s reproducibility and safety, reporting T-junction dehiscence in 28.6% of cases and no major BREAST-Q specific complications, with a mean follow-up of 8 months. In contrast, our results show a significantly lower rate of short-term complications, with only 1 case of seroma (6.7%) observed in our cohort. Similarly, Beidas and Rubin¹⁰ reported seroma and dehiscence as the most common complications. Notably, to the best of our knowledge, our study provides extended clinical follow-up after DSPR mastopexy, with no revision surgery and no clinically apparent recurrent ptosis during a median 5-year follow-up. However, objective photometric assessment of dermal suspension stability and upper-pole fullness was not performed, and durability was therefore assessed clinically and through routine postoperative photography.

Moreover, nearly half of the patients in our cohort were active smokers before surgery, with cessation initiated in the preoperative period as part of our institutional protocol. Although smoking is widely known to impair wound healing, it also significantly increases the risk of skin flap necrosis and NAC necrosis—both major concerns in mastopexy and postbariatric body contouring procedures.^25,26 Despite this, no such complications were observed in our cohort. This suggests that structured short-term smoking cessation, when strictly enforced, may mitigate even high-risk complications traditionally associated with tobacco use. These findings align with other studies supporting the role of preoperative cessation in reducing surgical morbidity.^27–29 Nonetheless, they underscore the critical importance of rigorous preoperative screening, patient education, and adherence monitoring.

In addition to its favorable safety profile, aesthetic outcomes were consistently rated positively across all cases, as shown by the BREAST-Q questionnaire results. Our cohort reported high levels of satisfaction, particularly in the psychosocial and sexual well-being, satisfaction with breasts, satisfaction with information, and overall satisfaction with outcome domains. These scores are notably higher than those reported in some larger mastopexy series.^30,31 Additionally, we found that satisfaction with nipple position and alignment was high, supporting the DSPR mastopexy technique’s ability to restore upper-pole fullness, reposition the NAC, and contour the lateral chest wall, making it a compelling solution for addressing the complex sequelae of MWL. Unlike conventional mastopexy techniques that rely on weakened, inelastic skin, DSPR uses autologous dermoparenchymal flaps to provide durable structural support and long-lasting contour.^19,32 However, nipple sensation scored significantly lower, which may reflect the tradeoff between extensive reshaping and sensory outcomes in complex MWL breasts and underscores the importance of preoperative counseling regarding potential sensory changes.^33–35 Physical well-being domain scores were relatively low and showed greater variability. This reflects common long-term sequelae of extensive dermoparenchymal reshaping and the high-risk nature of this surgical population. It also suggests that symptom burden may differ substantially across patients and should be explored further with standardized baseline and longitudinal PROM collection in future studies.

Limitations

First, this study is limited by its small sample size and retrospective, single-center design, which increases the risk of selection and measurement bias and limits generalizability. Second, the absence of a control group or comparison with alternative mastopexy techniques restricts our ability to evaluate the relative benefits of the DSPR approach and may reflect selection and surgeon-experience effects. Third, we did not perform standardized photometric or 3-dimensional imaging measurements. Hence, our assessment of long-term shape maintenance relied on clinical evaluation and PROMs rather than objective photometric analysis. Finally, although PROMs were incorporated, they were implemented only after the study had begun and were collected postoperatively, without standardized preoperative baseline assessments. Future prospective studies with larger cohorts, pre- and postoperative patient-reported outcomes, and long-term follow-up are needed to validate and expand upon these findings.

CONCLUSIONS

DSPR mastopexy offers a reliable, safe, and anatomically sound approach for breast reshaping in postbariatric patients. In our cohort, the technique demonstrated low complication rates, sustained aesthetic outcomes, and high patient satisfaction as shown in postoperative BREAST-Q questionnaire results, at a median 5-year follow-up. These findings underscore its value in addressing the complex deformities following MWL. Although our sample size was limited, the consistency of results supports broader clinical adoption. Further prospective, multicenter studies are needed to confirm long-term efficacy and optimize patient selection.

DISCLOSURE

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