Breast Reshaping after Massive Weight Loss

Abstract

After massive weight loss, breasts have poor shape, projection, and skin elasticity. The nipples are distorted and ptotic. Mastopexy is difficult and historically includes the use of excess nearby tissues. The senior author reviews his experience with 24 patients over the past 4 years. Body contouring is offered after the weight loss is stable. Breasts may be reshaped by mastopexy and/or augmentation; three examples are presented. More often the breasts are reshaped during an upper body lift. This lift is a reverse abdominoplasty that ends along the inframammary fold scar of the Wise-pattern mastopexy and extends laterally along the back roll. When the breasts need enlargement, nearby discard tissue is used for augmentation. The spiral flap has been devised for that purpose. When more tissue is needed, silicone implants are used. The long inframammary scar of the McKissock vertical bipedicle mastopexy forms the junction between the breast and reverse abdominoplasty. Proper inframammary fold construction is pivotal to the upper body lift. We have successfully combine breast reshaping with upper body lift for this difficult deformity after massive weight loss and present two demonstrative examples. Breast reshaping is best performed during an upper body lift.

Breasts change dramatically after massive weight loss. The reduced volume of fat results in poor shape, projection, and skin elasticity. Most breasts resemble a pancake, with distorted and ptotic nipples. Since joining the Bariatric Center of the Minimally Invasive Surgery Center of the University of Pittsburgh in late 1998, the senior author (D.J.H.) has contoured more than 70 patients with weight loss between 80 and 230 pounds. The breast deformity has been treated in isolation or as part of the upper torso deformity in 24 patients. This is a report of an evolving experience for improving breast shape and serves as an introduction to the spiral flap for breast augmentation.

BACKGROUND

Following the initial success of intestinal bypass surgery for managing obesity in the 1970s, Zook established the foundation for body contouring.¹ After a complete examination, all indicated surgical procedures were identified, followed by a coordinated surgical plan, “so that as many as possible can be done simultaneously.”¹ With two or three teams working simultaneously, the arms and breasts could be contoured at the same time as the belt lipectomy.^1,2 He declared post–weight loss contouring not aesthetic, primarily due to the scars.² Loosely hanging breasts were “an extremely difficult problem.”¹ He cited others' and his own experiences that normally discarded flaps should be de-epithelialized and placed deep in the breasts.¹ He applied the Pitanguy mastopexy with de-epithelialization of the keyhole as well as the whole undersurface of the breast, which was then under turned upward beneath to give it bulk and forward projection.¹ The inferior incision sometimes needed to be carried posteriorly around the trunk to remove undesirable bulk and to correct skin redundancy of the back and arms.¹

Contemporaneously, Palmer et al preferred to resect only one area at a time because of the extent of each excision.³ Recognizing the skin folds below and lateral to the ptotic breasts, his group aimed to build up the breast, “using the loose tissue surrounding it.”³ They used the Wise pattern⁴ and popular McKissock⁵ vertical de-epithelialized bipedicle nipple mammoplasty to gather the remaining glandular tissue under the nipple. In all three patients they combined this “with a wide excision of the submammary fold.”³ In 1979, Shons noted the variety of breast presentations after massive weight loss, preferring the McKissock technique with removal of excess skin through the Wise pattern.⁶ None of these authors demonstrated their breast reshaping technique.^1,2,3,6

The identification and use of the superficial fascial system (SFS) for high-tension closures of the skin was pioneered by Lockwood.⁷ Permanent suture closure of the SFS improved projection and scars following reduction mammaplasty and mastopexy.⁸ For tightening the loose inframammary fold (IMF) and improved breast projection, he advocated fixing the IMF at “the appropriate elevated position by nonabsorbable sutures from the SFS of the inferior skin wound edge to the underlying muscular fascia.”⁸

THE EVALUATION

The goals of body contouring surgery are to remove loose skin and excess fat followed by reshaping the remaining tissues into an attractive gender-specific form with as few scars and stages as possible. After massive weight loss, the breasts sag and flatten. In some, the breast volume remains excessive and, coupled with severe ptosis, results in back and shoulder pain. In most, the atrophy is profound, leaving an inadequately filled skin sack. Midtorso rolls of skin and fat may lie beneath and lateral. These unattractive breasts, contiguous with excessive midback rolls, may be difficult to manipulate into and confine to brassieres.

PRINCIPLES OF TREATMENT

Body contouring is offered as soon as the weight loss is stable, as no further skin shrinkage and a slight weight gain are anticipated. Breast reshaping is best performed within the context of the torso deformity. When the breasts need enlarged, nearby tissue is used for augmentation. The inferolateral breast spiral flap technique has been devised for that purpose. When more tissue is needed, silicone implants are used.

Women with massive weight loss seeking abdominoplasty and breast reduction need to understand that these back rolls are best treated by direct excision followed by long, tight suture line closure. We incorporate reshaping of the breasts into the upper body lift.⁹ The upper lift consists of raising the IMF, a reverse abdominoplasty, excision of the midtorso back rolls, and reshaping the breasts. A total body lift consists of an upper body lift combined with a lower body lift and circumferential abdominoplasty.⁹ Due to the magnitude of the case, the total body lift is usually a two-staged procedure. A single stage is best for young, healthy, and small patients.⁹ The single-stage approach better narrows the waist, by virtue of pulling both inferiorly (at the belt line) and superiorly (at the bra line).

ISOLATED BREAST RESHAPING

Diffuse breast atrophy with mild nipple ptosis and minimal midtorso laxity may be treated with silicone implant augmentation and a mastopexy. When the implant becomes the dominant volume of the breast, gel fill is preferred. It is softer and more cohesive than saline. Lax breast tissue is unlikely to adequately support a saline-filled implant, resulting in rippling. Figure 1 shows a 32-year-old woman before and 10 months after the use of a 450-mL gel-filled implant with a concentric ring mastopexy immediately following abdominoplasty, lower body lift, and medial thighplasty.

Figure 1.

(A, C) Preoperative and (B, D) 10-month postoperative photographs of a 32-year-old woman. She is 5′ 6″ and weighs 150 pounds and has lost 130 pounds through dieting and exercise. After a lower body lift, medial thighplasty, and abdominoplasty, a concentric ring mastopexy and a partial subpectoral 450-mL smooth-walled gel-filled implant augmentation was done. The nipple position, areolar shape, and breast shape, size, and feel are excellent.

For large, broad-based, and severely sagging breasts, both Wise-pattern/McKissock and vertical-pattern breast reductions have been done.¹⁰ Because of the excess skin, the nipple should be marked slightly medial than the nipple line, ∼11 cm from the midline, or the final position will be lateralized. The generous retention of breast parenchyma will push the new nipple superiorly so the new nipple's location should be planned low (Fig. 2).

Figure 2.

(A, C) The preoperative and (B, D) 1-year postoperative photographs of a 45-year-old, 5′ 4″, 170-pound woman who lost 120 pounds after gastrointestinal bypass. She had an abdominoplasty and Lejour-type minimal breast reduction. The new nipple position was not adjusted medially and consequently is slightly lateralized. She is pleased with her breasts and lower abdomen, but regrets leaving behind the loose upper abdominal skin.

Although the vertical techniques avoid the inframammary scar, it is difficult with severe glandular ptosis to adequately reduce the excess skin between the areola and IMF. This is because the vertical elliptical excision between the areola and IMF is often greater then 15 cm in length. The reshaped lower breast will rest on the chest, which is objectionable. To minimize this outcome, generous and rather thin skin flaps are undermined about the entire inferior breast to redistribute the skin along the shortened purse-string vertical closure. Lateral rolls of puckered skin may not flatten and might need to be removed later.

The major advantage of the vertical techniques is the reliance on the direct approximation of the medial and lateral parenchymal flaps to narrow and project the breasts. The nonresilient, inelastic breast skin in the weight loss patient cannot be relied on to hold the new breast shape. The vertical techniques raise the lowered IMF. The vertical techniques avoid the inframammary scar, which is not really a concern in this patient population.

For reshaping large pancake breasts, vertical-pattern mastopexy is modified with two central de-epithelialized pedicles. The superior flap includes the nipple-areolar complex and is folded as the areola is sewn to its new position. The inferior tonguelike flap, extending from IMF to inferior areola, augments the breast as it is repositioned directly over the pectoralis muscle fascia and under the approximated medial and lateral parenchymal flaps. Then or at a later stage the brachioplasties are vertically extended with skin excisions along the midlateral chest to remove some of the lateral chest roll and impart lateral definition to the breasts (Fig. 3).¹¹

Figure 3.

(A, C) The preoperative and (B, D) 1-year postoperative photographs of a 42-year-old, 5′ 7″, 190-pound woman who lost 140 pounds after gastrointestinal bypass.¹¹ She had vertical mastopexies, a lower body lift, circumferential abdominoplasty, and medial thighplasty and then 4 months later a facelift and brachioplasties that extended down her chest lateral to her breasts. A superior de-epithelialized vertical pedicle was used to raise the nipple and an inferiorly based de-epithelialized pedicle to fill the central breast.

UPPER BODY LIFT/ BREAST RESHAPING

The upper body lift is a reverse abdominoplasty that ends along the IMF scar of the Wise-pattern mastopexy and extends laterally with excision of the back rolls (Figs. 4–8). It is performed immediately (as the second part of a single-stage total body lift) or some months after the circumferential abdominoplasty and lower body lift.⁹ Moderate breast atrophy dictates the need for soft tissue augmentation from upper abdominal and lateral chest discard.

Figure 4.

These four views show the markings for a total body lift and brachioplasties on a 5′ 8″, 195-pound, 35-year-old woman who lost 180 pounds after bypass. She had a prior abdominoplasty. A transverse line over the sternum marks the new IMF. (A, C) The extended Wise pattern and both ends of the abdominoplasty. (B, D) Continuation of the pattern around the chest, surrounding redundant midback rolls, with an aim to closure in the bra line. Augmentation will be from de-epithelialized inferior and lateral flaps of skin. The vertical chest extensions of the brachioplasties will meet the lateral extension of the back rolls.

Figure 5.

The operative sequences for the right-side upper body lift. (A) The extended Wise pattern. To avoid midline excision the vector of pull is superiolateral, as indicated by the arrows. (B) The de-epithelialization is completed and the reverse abdominoplasty edge has been secured along the sixth and seventh ribs to create the IMF. (C) The superior, suprapectoral space opening to receive the de-epithelialized flaps, which are supported by the surgeon's hand. (D) The clockwise spiral rotation of the flaps into position.

Figure 6.

The immediate result of the total body lift shown in Figures 4 and 5. The augmented breasts project well and are proportional to the reshaped hips.

Figure 7.

(A-D) The 9-month postoperative view compares to Figure 4. Scars are even and lie within a two-piece bathing suit, which is reflected by the tan lines. The raised arms reveal no restricting or unsightly scars along the axilla or IMF.

Figure 8.

Two-stage body lift. (A, D) Preoperative lower body lift, medial thighplasty, and circumferential abdominoplasty views. (B, E) Preoperative upper body lift views 1 year later. (C, F) Final postoperative views 1 year later of a 200-pound, 5′ 8″, 33-year-old woman who lost 230 pounds after bypass surgery. Preoperative upper body lift views reveal that the first stage did nothing to improve the midtorso. The new IMF and nipple positions are registered over the sternum. The excision of skin is planned with an upward and outward reverse abdominoplasty as indicated by the arrows. A Wise-pattern mastopexy is drawn without the areolar cut out. Final postoperative views show the 1-year result of the torsoplasty and breast reshaping as well as bilateral brachioplasties.

Planning for the upper body lift begins after the lower lift/abdominoplasty is drawn or previously performed (Fig. 4). If a single-stage procedure is planned, then the anticipated inferior torso skin closure tensions are considered. With the patient upright, the existing IMF, which has descended toward the costal margin, is identified, marked, and registered transversely over the sternum. The breast is held upward to similarly sight and draw the new IMF.

The reverse abdominoplasty removes the excess upper abdominal skin transversely, followed by undermining and advancement of the inferiorly based flap. To judge the excision, the excess upper abdominal skin is pushed upward and laterally until the umbilicus is pulled. Obesity and/or marked costal margin flare makes this maneuver difficult to judge. The end of the flap is marked at the new IMF and continued laterally along the bra line. Because the lateral skin redundancy is more than medial and a transsternal scar under tension may hypertrophy, we rarely excise across the midline. Symmastia is an exception. In most cases the excess upper abdominal skin is pushed superiorly and laterally and a dipping transverse line is made that demarcates the removal of this skin and places the closure along the newly designated IMF.

The reverse abdominoplasty incision line continues laterally and inferior to the midtorso back roll. The excess back skin and fat is gathered and pinched and a superior transverse line of excision is drawn near the midback to the lateral limb of the Wise pattern. After the back roll is excised, a bra will cover the suture line. Augmentation of the superior pole of the breast will be provided by a de-epithelialized lateral extension of the central breast pedicle that includes the lateral 50% of the back roll. With augmentation, the Wise pattern is modified according to the fill flaps, to improve projection and reduce skin tension. The anticipated nipple position is lowered, and the vertical limbs are lengthened.

With the single-stage total body lift, the upper body lift continues after the lower body lift is completed. The excess midback skin is excised and the defect closed in two layers while the patient is prone. The lateral portion of the back roll is left attached to the central breast.

Then the patient is wrapped in a sterile surgeon's gown and turned. The high lateral tension abdominoplasty is completed with little undermining. Next, the previously marked upper abdominal transverse incision is reconsidered by pushing the skin superiorly to its higher IMF location. When confident of the amount of redundant upper abdominal skin and fat and the need for additional breast bulk, this skin, the bipedicle breast flaps, and lateral roll are de-epithelialized (Fig. 5). The transverse incisions at the superior margin of the reverse abdominoplasty flap are made, and the flap is undermined over the rectus abdominis fascia toward the costal margin. Only in the midline is there continuity with the undermining of the abdominoplasty. A broad midabdominal band of undissected skin with its perforating vasculature is left behind. The inferior breast is undermined to the new IMF, which is several centimeters superior. Interrupted, large braided, permanent sutures are placed through the SFS and along the sixth rib. After about eight sutures are placed, the flap is pushed up to the IMF and the sutures are pulled taunt and sequentially tied.

With the IMF established, the reshaping resumes by mobilizing the de-epithelialized lateral thoracoepigastric flap. It is raised lateral to medial including the fascia of the latissimus dorsi and serratus muscles until a row of perforating vessels along the anterior axillary line are identified and preserved if possible. Both the lateral and inferior flaps have been de-epithelialized in continuity with the inferior breast pedicle. The inferior breast flap is folded against the inferior breast pedicle and advanced laterally as the lateral thoracoepigastric flap is turned along the lateral breast and the end positioned under the superior nipple pedicle. Sutures secure the dermis to the pectoral fascia for superior pole fill and along the anterior axillary line for improved lateral fullness and definition.

For the right breast, a clockwise spiral of inferior, lateral, and breast de-epithelialized flap is made. On the left, the composite flap spirals counterclockwise. The nipple is then sutured into position and the medial and lateral flaps are approximated. If the vertical lengths of the flaps are too long, they can be shortened at this time. See Figure 6 for results on the operating room table, Figure 7 for the result at 9 months. Figure 8 shows a two-stage total body lift. If the soft tissue fill remains inadequate, a pocket is created through the medial breast flap and under the central breast to accommodate an implant.

DISCUSSION

With the increased efficacy, safety, and popularity of bariatric surgery nationwide, plastic surgeons will treat more patients after weight loss. With attention to postoperative breast shape and contour and proper positioning of extensive incisions, most patients have improved proportions with lengthy but strategically placed scars. Hence, we disagree with Zook^1,2 on postponing surgery for an extra year and that patients will have unaesthetic results.

Breast reshaping should be integral to an upper body lift. Tissues that would be discarded during a reverse abdominoplasty and back roll excision are de-epithelialized and spiraled around the central breast like the 1920s Biesenberger technique.¹²

The IMF is a fascial condensation adhering dermis to the chest muscle fascia along the sixth rib. Proper IMF construction is pivotal to the upper body lift. It contributes to breast shape and position. It hides the anterior scar of the reverse abdominoplasty under the breasts. It allows for maximum removal of redundant and lax midtorso skin flaps by a secure fixation to the chest wall. Although the new IMF establishes the end of the reverse abdominoplasty, its positioning focuses on the breast. The new IMF lies along the brassiere line and relates to the ultimate nipple location.

Secure fixation is essential. For creation of a new IMF after tissue expansion for breast reconstruction, an incised de-epithelialized dermal flap to chest wall fascia is considered optimum.^13,14 To avoid parallel transverse breasts scars, others favor internal suturing of subcutaneous fascia or dermis to the chest wall.¹⁵

The IMFs we have created approximate the SFS to muscular fascia,⁸ and despite considerable tension caused by the reverse abdominoplasty, they barely drift. The anterior thoracic SFS is well defined with sparse fat. We minimize injury to the SFS by scalpel incision. The suprafascial undermining goes to the coastal margin or beyond. We place interrupted, large braided, permanent sutures with generous vertical bites using tapered needles from just lateral to the sternum to the anterior axillary line. We tug on each suture is ensure secure placement. By forceful upward push on the reverse abdominoplasty flap, tension is relieved as the sutures are tied. They may temporarily dimple the skin. This closure is painful for weeks. No IMF scar has hypertrophied, except for the lateral, unsecured extensions.

The spiral breast flap is a combined inframammary and lateral thoracoepigastric flap that augments and projects the breast. These flaps are tissue salvaged from upper abdomen and lateral back roll that would otherwise be discarded. The de-epithelialized lateral thoracoepigastric flap is based at the anterior axillary line and includes underlying muscular fascia. Similar flaps as long as 22 cm have survived, except in high-risk patients.^16,17 The blood supply is from lateral branches of the superior epigastric arteries and ventral perforators of the sixth and seventh intercostals vessels.¹⁶ In the weight loss patient the perforating vessels are large, which permits some vessel interruption during mobilization.

Based on our 5-year experience, we have successfully evolved a breast reshaping technique with an upper body lift for patients after massive weight loss.