- Carefully assess parenchymal volume, amount of redundant skin envelope, and extent of lateral skin/fat roll.
- Consider order of breast reshaping in association with other planned body-contouring procedures.
- Plan Wise pattern marking to encompass lateral chest wall tissue in order to eliminate skin/fat roll and also allow for autologous volume augmentation.
- Deepithelialization of entire Wise pattern and complete degloving of parenchyma preserves breast volume and provides broad dermal surface area.
- Permanent suspension sutures secure dermis to rib periosteum, and multiple plication sutures in dermis allow precise control of breast shape.
The nature of breast deformities after weight loss Postbariatric patients manifest severe breast deformities that are very different from those seen in the traditional mastopexy candidate. Severe volume deflation with distortion of shape and inelastic skin is common. There are four problems. 1. There is a tendency toward significant and sometimes asymmetric breast volume loss with a deflated and flattened appearance.
2. There tends to be dramatic loss of skin elasticity, as well as tremendous skin excess relative to the parenchymal volume.
3. The nipples are usually too medial in position.
4. A final peculiarity, fairly unique to this population, is the presence of prominent axillary skin, or in many cases a fatty roll. This blurs the border between the lateral breast and chest wall, sometimes forming one continuous roll of tissue (Fig. 4.1).
The role of short scar techniques To achieve an aesthetically pleasing breast in the setting of these deformities, there must be reshaping of the deflated breast parenchyma and augmentation with autologous tissue to re
store superior fullness and projection. The skin envelope must be reduced and prominent axillary skin rolls eliminated. It is the authors’ view that short scar techniques are inadequate in handling the redundant inelastic skin envelope in these patients. Moreover, short scar techniques cannot properly address the lateral skin excess.
Approach used by the authors The authors have developed and refined a technique using the principles of dermal suspension and total parenchymal reshaping. An extended Wise pattern encompasses and eliminates lateral skin rolls, while at the same time providing additional tissue that may be used as necessary for volume augmentation. Deepithelialization of the entire Wise pattern creates a broad dermal surface area that can be plicated to precisely control breast shape and can be suspended to the chest wall.
Background The technique developed by the authors for the weight loss patient is based on lessons learned from the historical development of breast-reshaping methods. Schwarzmann’s early contribution demonstrating the importance of dermal blood supply was essential.1 Beisenberger’s conceptual revolution of total dissociation of the skin envelope from the glandular tissue was invaluable in the development of this and many other procedures.2 While the Beisenberger technique had great support and longevity, surgeons continued to produce technical refinements. Thorek is credited with introducing the free nipple graft in the 1920s,3 and this method provides a valuable lifeboat for breast surgeons who note poor nipple perfusion in the operating room. The 1950s saw Wise describe a technique to control the skin envelope in a manner that accentuates breast shape.4 In 1960, Strombeck described a horizontal bipedicled procedure with enhanced nipple vascularity.5 A significant contribution came from McKissock’s vertical bipedicled flap, which facilitated the creation of a more natural-appearing breast.6 In 1963, Skoog produced work supporting the transposition of the nipple areolar complex (NAC) on a unilateral vascular pedicle.7 Eventually, Rubiero described,8 and Courtiss and Goldwyn championed the inferior pedicle with the Wise pattern of scars.9 The various approaches applied in the
historical development phase of breast surgery demonstrated that safe and effective reshaping could be accomplished through multiple techniques based on sound principles. Many techniques dictated that the shape of the breast was contingent on the pattern and amount of skin excised, and ultimately relied on skin support to maintain shape.10 Untoward effects of this approach include parenchymal ‘bottoming out’, recurrent ptosis, and lengthy scars. Because of these realizations, surgeons sought to create ways to uplift and reshape the breast in a more durable fashion, while at the same time minimizing scar formation. Lassus pioneered the vertical mammoplasty, with volume control via a central wedge resection, transposition of the NAC on a superior pedicle flap, and a vertical scar to finish.11,12 Lejour expanded on this by adding regional suction lipectomy, glandular undermining, and sub
sequent glandular fixation to the chest wall.13 Chen and Wei preferred a variant of the vertical mammoplasty, the S approach.14 To further pursue reliable parenchymal shaping with minimal scarring, Exner and Scheufler devised a vertical scar variant with segmental central parenchymal resection and concomitant dermal suspension via deepithelialized dermis caudal to the NAC and ultimately fixed to the chest wall.15 Progress toward desirable contour with minimal scarring was furthered by Benelli and his periareolar ‘round block’ technique.16 Hammond utilizes a technique with fixation of the pedicle to the chest wall with permanent sutures, and closure with a periareolar scar with a variable-length vertical component.17 Goes described a ‘double skin technique’ and ultimately utilized mesh to achieve desirable breast contour with greater support.18
4 Approach to the breast after weight loss
(a and b) Representative patient showing classic deformities of severe volume deflation and medial nipple position. (c and d) Representative patient demonstrating prominent lateral roll of skin and fat that distorts the border between breast and chest wall.
Many surgeons focused on strategies to improve and maintain upper pole fullness, and these techniques often involved fixation of breast tissue to adjacent structures. Pitanguy restricted resection to only the inferior pole, and utilized a ‘straight resection’ or ‘inverted keel’ for firmer breast tissue. Closure of medial and lateral pillars of parenchyma and an inverted T incision finished his procedure.19 Cerqueira’s approach was to create a superior pedicle, resect a central block of parenchyma, and subsequently secure the dermoglandular pedicle under the pectoralis.20 Frey’s contribution allowed for parenchymal contouring and suspension via a dermal brassiere fixated to the anterior thoracic wall with non-absorbable suture, and complete elimination of the medial component of the scar.21 Building upon the concept of a dermal bra, Qiao et al. devised an approach that resected a crescent of glandular tissue superolaterally, with dermal fixation to the pectoralis fascia.22 Gulyas’s periareolar techniques also relied on manipulation of the ‘dermal cloak’ to support and shape the breast.23 Graf and Biggs created an inferior dermoglandular pedicle that they passed under a loop of pectoralis and secured to the pectoralis fascia. The NAC is carried on the elevated breast, and the inferior flap is fixed to the pectoralis fascia in the upper pole to ensure upper pole fullness with closure of medial and lateral pillars behind the flap.10 Lockwood achieved his results via a modification of the Wise pattern, with the primary supportive element being non-absorbable sutures in the superficial fascial system to decrease dermal tension and subsequent scarring.24 Many important principles are embodied in the techniques described. However, when considering the complex deformity seen in the massive weight loss patient, none of the above procedures seem to be ideal. Moreover, it becomes obvious that short scar techniques are of limited value in this patient population. What is required is a technique that allows for: • precise and symmetric NAC positioning, • precise control of parenchymal breast shape and contour, • possible autoaugmentation in the volume-deficient patient, and • control of the remaining skin envelope. In our technique, we make use of a well-vascularized central dermoglandular pedicle.2,16 A modification of the traditional Wise pattern allows for precise control of the skin envelope and NAC position.4 The dermal suspension techniques of Qiao, Frey, Cerqueira, and others prompted our use of parenchymal suspension and extensive sculpting via dermal plication and fixation to the chest wall.15,18,20–23 Holmstrom’s lateral thoracodorsal transposition flap for breast reconstruction after mastectomy facilitated the notion of autoaugmentation via recruitment of redundant axillary tissue.25 Medial fullness is assured via the elevation and manipulation of a medial breast flap. The technique described below has the advantages of correcting, with a low complication rate, the severe breast deformities associated with weight loss. Notably, the deformity of a lateral axillary roll can be eliminated and used to augment breast volume. The disadvantages of this technique include:
• a lengthy scar,
• considerable time in the operating room for the extensive deepithelialization, and
• a high degree of ‘intraoperative tailoring’ that cannot be premarked. Despite the disadvantages, this technique is safe and reliable for restoring a youthful breast shape in the massive weight loss patient. Great control over both skin envelope and parenchymal shape may be gained with this procedure.
Patients with mild breast deformities following weight loss should be considered for traditional mastopexy techniques, including short scar approaches. However, existing mastopexy techniques are not always adequate to achieve a good aesthetic result with these deformities when faced with the following clinical findings.
• Profound breast volume loss with flattening of the parenchyma against the chest wall.
• A redundant, inelastic skin envelope.
• Grade 3 nipple ptosis.
• Medialization of the NAC.
• The presence of a prominent axillary roll of skin that extends from the lateral breast. We have identified few contraindications for the use of this technique. Because of the extensive flap dissection, we have avoided performing this procedure on active tobacco users. As with all breast reshaping patients, we perform a thorough history and physical examination for breast disease, as well as require mammography imaging consistent with the American Cancer Society screening guidelines. Scars from previous breast surgery may present a relative contraindication if they pose a risk to perfusion of undermined tissues. Careful evaluation for parenchymal volume is undertaken, as well as asymmetry. The lateral breast region is inspected for a significant skin roll, and an assessment is made regarding the amount of tissue that may be mobilized from the lateral chest wall for autologous breast augmentation. In the case of significant asymmetry, we will either selectively augment the smaller breast using lateral chest wall tissue or, if this is not possible, reduce the larger breast to match the smaller one. The surgical goals for breast reshaping in the face of these deformities are to:
• use all available breast tissue, and also have the ability to recruit additional autologous tissue;
• address the nipple position;
• restore superior pole projection;
• reshape the skin envelope without relying on it for support;
• eliminate the lateral skin roll; and
• create a discrete ‘lateral sweep’ to the breast shape. The technique we describe, using the principles of controlled parenchymal reshaping and dermal suspension, will meet these goals. This safe and reproducible technique yields a youthful breast shape in a very challenging population.
Marking The surgical technique is based on a Wise pattern with preservation of a central pedicle. The nipple position is referenced to the inferior mammary fold, and moved to a more lateral position along a symmetrically drawn breast meridian. The vertical limbs are marked at 5cm. The lateral portion of the Wise pattern is extended posteriorly to encompass the axillary skin roll and provide additional autologous tissue for breast volume. The Wise pattern can be extended to the posterior axillary line and beyond, depending on the extent of the lateral skin roll and the amount of tissue desired for autologous breast augmentation (Fig. 4.2). The robust blood supply of the lateral thoracic region allows for a significant amount of tissue to be safely mobilized to the breast. We must make an important point here: The area of skin resection to alleviate the lateral skin roll may extend beyond the portion of the Wise pattern to be deepithelialized (i.e. a portion of the lateral ‘wing’ of the Wise pattern may be deepithelialized and saved to assist in the reshaping and add volume, while the remainder is simply excised to eliminate the skin roll). This flexibility in design allows the surgeon to control the skin envelope and titrate the amount of lateral tissue to mobilize to the breast.
Technique The entire region within the Wise pattern is deepithelialized
(Figs 4.3 and 4.4)
. The breast parenchyma is then completely degloved by raising a 1cm-thick flap overlying the breast capsule. Once the chest wall is reached, undermining continues over the pectoralis major fascia to the level of the clavicle. Medial and lateral flaps of breast tissue are mobilized by undermining over the chest wall. Care is taken to preserve significant perforating vessels that enter the tissue flaps near the
base. The lateral flap is trimmed to desired size, as necessary. The nipple survives on a healthy central pedicle. The next step is suspension of the central dermal extension to the chest wall. This is performed with a 0 braided permanent suture in a mattress fashion. The dermis is firmly tacked to the periosteum of a selected rib along the breast meridian. This carefully placed suture must pass through the pectoralis muscle, and relies on palpation of the rib with the non-dominant hand to guide the needle pass. The choice of rib level for fixation is made intraoperatively based on the distance between the dermal edge and the nipple (i.e. how NAC position is affected by height of suspension). This is most often the second rib. The suspension should raise the level of the nipple close to the intended final position. The lateral breast flap is then suspended and secured to the chest wall by tacking to rib periosteum in a similar manner. The lateral flap dermal suspension suture will be very close to the central suspension suture, although a lower rib level may be selected to provide the desired shape. This will create a discrete lateral curvature to the breast shape and replace the unsightly blending of breast tissue with the lateral chest (Fig. 4.5). The medial breast flap is then suspended and secured to the chest wall. With the suspension points established, control of the parenchymal shape is then gained. The broad surface area of dermis is meticulously plicated with running absorbable sutures to adjust the shape. Braided absorbable 2–0 sutures are used. The process starts with approximation of the dermis of the lateral flap to the central dermal extension. This is followed by plication of the medial flap dermis to the central dermal extension. The inferior pole of the breast is then plicated to shorten the nipple to inframammary fold (IMF) distance and to increase projection. The authors have learned to do each suspension and plication step simultaneously on both breasts rather than completing one breast and moving to another. This permits better symmetry.
4 Approach to the breast after weight loss
Figure 4.2 (a) Wise pattern marking showing correction of medial nipple position and (b) extension of pattern to address lateral skin roll and provide additional tissue for autoaugmentation.
After initial placement of plication sutures, a fine-tuning process follows in which additional plication sutures are added. Sutures may be necessary to secure the lateral breast flap to the lateral chest wall fascia. Constant redraping of the skin flap during the shaping process helps guide both major and minor adjustments to breast form. If the abdominal wall tissues are very loose, a decision may be made to secure the superficial fascial system layer of the dissected edge of the abdominal wall to the periosteum of the fifth rib. This will restore IMF position. For closure, the authors favor using a half-buried mattress suture to secure the dermal edges at the ‘triple point’ along the IMF. The dermis around the nipple may be incised part-way
around the circumference to release any tethering as necessary. Intradermal sutures are then used to complete the closure, and suction drains placed in each lateral breast. A lightly compressive chest wrap is then placed. Restoration of breast shape and symmetry can be achieved in difficult cases with this technique. Patient satisfaction has been high in all cases. Pre- and postoperative results are shown in Figures 4.6–4.8.
Optimizing outcomes • Extend the Wise pattern as far lateral as is necessary to eliminate the skin rolls.
Figure 4.3 (a) The patient is marked with a Wise pattern that extends laterally to encompass the redundant axillary roll. The entire area of the Wise pattern is deepithelialized, preserving an extensive dermal surface. (b) The breast parenchyma is degloved by raising a 1cm-thick flap and then continuing the dissection superiorly just superficial to the pectoralis fascia. Medial and lateral flaps of dermis/breast tissue are mobilized from the chest wall. The central dermal extension is elevated and secured to the chest wall (usually rib periosteum) using braided nylon suture. (c) The lateral breast flap is elevated to create the lateral curvature of the breast mound, and the dermis secured to the chest wall near the previous fixation point. The lateral flap can be extended posteriorly on the chest wall to provide extra tissue for autologous volume augmentation. (d) The dermal edge of the medial breast flap is fixed to the chest wall. A running braided suture is used to approximate the dermal edges of the lateral flap and central dermal extension. Dashed lines show the pattern of plication used. The pattern of plication may be individualized to achieve the best breast shape in each patient. In general, there is a later component, a medial component, and an inferior component that corrects the “bottomed out” appearance and increases projection.
• The entire lateral wing of the Wise pattern may be deepithelialized and preserved to add volume to the breast, as needed. Conversely, a smaller portion may be preserved and the remainder excised. • Keep the breast flap approximately 1cm thick (or greater), and once at the level of the pectoralis fascia, continue undermining superiorly above the level of the second rib. • Avoid performing this operation on smokers because of the risk of flap necrosis. • Plication of the dermis is most effective on the lateral and inferior aspects of the breast, where it serves to increase projection and create a distinct lateral curvature to the breast mound.
• If the nipple is tethered, the surrounding dermis may be partially incised to release it. A robust central pedicle supports the nipple and allows this to be done safely.
Postoperative care and course • The authors use a lightly compressive breast dressing for the first 5 days, and then ask the patient to wear a sports bra with no wires for the next month. • Drains are maintained for the first 48h and then discontinued if the output is decreasing. • Heavy lifting and exercise is prohibited until 4 weeks after surgery.
4 Approach to the breast after weight loss
Figure 4.4 (a) The dermis of the medial breast flap is approximated to the central dermal extension using a running suture. The dermis on the inferior pole of the breast is plicated with a running suture to shorten the distance between areola and inferior mammary fold to approximately 5cm. (b) The dermis along the lateral breast is secured to the lateral chest fascia (not rib pereostium) with permanent sutures to increase projection and accentuate the lateral curve of the breast. The breast parenchyma is now firmly secured to the chest wall, and the shape has been adjusted using the plication sutures. (c and d) The breast skin flap is redraped and closed with absorbable intradermal sutures over a drain. If the nipple is tethered and pointing in an inappropriate direction, the dermis adjacent to the nipple is scored to release the tension. Because of the robust pedicle, scoring of the dermis can be safely performed along part of the circumference, if necessary.
Figure 4.5 (a) Intraoperative photographs showing extensive de-epithelialization. (b) Suspension of the central dermal extension bilaterally. (c) Plication sutures in place. (d) Redraping of skin flap. Pre- and postoperative photographs of this patient are shown in Figure 4.6.
Figure 4.6 A 46-year-old patient treated with this mastopexy technique following a 160-lb (73kg) weight loss. (a, c, and e) Preoperative and (b, d, and f) 6month postoperative views.
Figure 4.7 A 57-year-old patient following 130-lb (60kg) weight loss. Preoperative views (a and b) show severe ptosis with lateral roll. Intraoperative views (c and d) demonstrate control of parenchymal shape with this technique, which is translated into restoration of aesthetic shape at 6 months postoperatively (e and f).
4 Approach to the breast after weight loss
Figure 4.8 A 41-year-old patient with ptosis, asymmetry, medialized nipples, volume loss, and severe lateral roll following 145-lb (66kg) weight loss. (a, c, and e) Preoperative and (b, d, and f) 6-month postoperative views demonstrate improvement in breast shape.
Complications Complications have been infrequent. In 48 cases, the following complications occurred. • One patient suffered a small postoperative hematoma in the lateral right breast during the early postoperative course; this was treated non-operatively. • One patient had a minor wound dehiscence (less than 1cm) at the confluence of incisions along the IMF; this healed rapidly with local wound care. • One patient underwent scar revision of a portion of the right breast medial incision in a minor procedure suite. There were no occurrences of major skin necrosis or nipple loss. Breast shape is shown to be fairly durable at 1 year (Fig. 4.9), with some settling of the inferior pole noted.
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Figure 4.9 The same patient shown in Figure 4.8: (a) preoperative view, (b) 6 months postoperative, and (c) 1 year postoperative. Some settling of the inferior pole breast tissue is observed.
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