Phẫu Thuật Tạo Hình Đường Nét Cơ Thể Và Hút Mỡ (Body Contouring and Liposuction)

117
Chapter | 12  Mammaplasty with L-shaped scar
FIG. 12.16  Inferior and lateral demarcation in L mammaplasty.
are performed on the breast which will be operated on, then
for certain the horizontal scars will be outside the mammary
folds, and they will be longer.
Finally, a safety triangle of skin is marked, about 1 to
2 cm in width, positioned on the bisection of the angle
between the meridian and a line passing through point M,
which will be placed at the end, below the areola so as not
to strangle the subareolar vertical suture (Fig. 12.17A, B).
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Ler Foneticamente
After glandular resection and cone mounting according to
the groups, lateral to medial closure is started, adjusting
AM oblique on AM horizontal (Fig.12.18A). It is difficult
to adjust this suture to coincide with the glandular border
edge. It will be necessary to readjust it in the end by remov­
ing a small “ear” at the lateral end of the horizontal suture
to coincide the suture with the glandular border edge. With
a flat hand, the breast is pushed down, forcing it toward the
upper abdomen. It is noted if the horizontal suture is well
placed in the lower mammary border edge up to its end.
Skin or fat remaining must be removed as above, and the
suture put on this new lateral submammary sulcus (Fig.
12.18B).
The lateral aspect of the vertical skin incision and its
associated subcutaneous tissue is smaller than the medial
(Fig. 12.18A). The suture attempts to adjust a vertical com­
ponent to another by taking more subdermal and subcutane­
ous tissue medially and less laterally (“semicolon suture”)
and always from the point I toward the point A. First, the
subcutaneous tissue is sutured, and after that the subdermalt
issue, finishing with skin suture.
In the subareolar region, the triangle of skin safety is
adjusted (laterally) (Fig. 12.19), resecting it partially in its
lower vertent, or superior or all of the triangle if it is desir­
able or necessary.
If there is no more periareolar skin excess, only the
areola position is adjusted, with removal of skin around it to
give proper tension. If skin excess still exists, the vertical
simple suture is finished discreetly (Fig. 12.20A), or with

118
PART | 3  Breast reshaping
FIG. 12.17  (A) The safety lateral triangle of the skin and complete demarcation. (B) Diagram of the safety lateral triangle.
A
B
FIG. 12.18  (A) AM obliqúe and horizontal sutured showing that the medial vertent is longer than the lateral vertent. (B) The movement of
the skin during the suture and the areola round block compensation.
A
B

119
Chapter | 12  Mammaplasty with L-shaped scar
FIG. 12.19  The adjustment of the safety triangle. It is possible to
resect it partially.
A
B
FIG. 12.20  (A) If skin excess does not exist, the final suture will be vertical. (B) If a little skin excess exists, the final suture will be VY. When
a big skin excess exists, an areola round-block compensation must be used (Fig. 12.18B).
FIG. 12.21  Final sutures. The length of the horizontal suture is
AM+ 2 cm.
the end in a V-Y shape (Fig. 12.20B), or in “areola round-
block compensation” (Fig. 12.18B).
The position of the new nipple site is marked 1 cm
below the apex of the cone, the skin excess is removed,
suturing the papillary muscle and the areola, always without
excessive tension (Fig. 12.21).
When the “areola round-block compensation” is made,
there will be a greater medial folding that is well distributed
along the medial half of the areola and which disappears
after 2 months. Large folds do not disappear and distort
the areola, as occurs with attempts to compensate a long
linear vertent with a smaller one. It is this procedure
that limits the use of skin compensations in L to AM up to
7 cm.
In the end, the horizontal scar should measure mostly
AM + 2 cm and the vertical one be equal to the amount left
in the glandular tissue of the apex (point A) to the base of
the mammary cone (Point I) (Fig. 12.21).
Within a few months there will be relaxation of the
sutured tissues; the upper pole is a little emptied, and the
lower pole is bulging because of greater or lesser skin
elasticity; the vertical diameter is reduced, the horizontal
width increases, and the areola “rises” to the apex of
the cone.
One centimeter below the apex is a moving average of
the areolar position, dependent on the skin and the shape
of the formed mammary cone. The longer the lower pole
and the shorter the higher, the greater the movement of
scales will be, and vice versa.
Gland and skin have to be examined separately, as well
as other changes and worked on individually, seeking the
highest symmetry.

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PART | 3  Breast reshaping
A
B
C
D
FIG. 12.22  One year of (A–C) pre- and (D–F) postoperative period.
E
F
FIG. 12.23  Asymmetrical breasts: the left breast reduction was made by reproducing the right breast cone using the L-scar technique.

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Chapter | 12  Mammaplasty with L-shaped scar
REFERENCES
1. Ricketts RM. The biologic significance of the divine proportion and
Fibonacci series. Am J Orthodontics 1982;81(5):351–70.
2. Peck H, Peck S. A concept of facial esthetics. Angle Orthod Appleton
1970;40(4):284–318.
3. Preston JD. The golden proportion revisited. J Esthet Dent
1993;5(6):247–51.
4. Gil CTLA, Médici Filho E. Estudo da proporção áurea na arquitetura
craniofacial de indivíduos adultos com oclusão normal, a partir de
telerradiografias axiais, frontais e laterais. Revista Ortodontia
2002;35:69–85.
FURTHER READING
Bozola AR, et al. Mamoplastia em “L”. Contribuição Pessaol. Ver
AMRIGS 1982;26:207.
Bozola AR. Breast reduction with short L scar. Plast Recontr Surg
1990;85(5):728–38.
Bozola AR. Reduction mammaplasty: preferred techniques. In: Goldwyn
RM, editor. Reduction Mammaplasty. Boston, MA: Little, Brown and
Company; 1990. p. 407–37.
Bozola AR, Ferreira LM, Sabino Neto M. Reconstrução mamária com
expansão prévia da área da mastectomia e preenchimento com retalho
TRAM desepidermizado. Rev Bras Cir Plást 2005;5:95–101.
Bozola AR, Longato FM, Bozola AP. Análise geométrica da forma da
beleza e da forma de prótese baseado na proporção Phi: Aplicação
prática. Rev Brasileira De Cir Plástica 2011;26:194–203.
Bulent A. Math and the Mona Lisa, The art and science of Leonardo da
Vinci. London: Harper Collins; 2004.
Brown D. The da Vinci Code: Special Illustrated Edition. GMT Editores
2004.
Eco U. Storia della belleza. Bompiani: RCS Libri S.p.A.; 2004.
Etcoff NL. Beauty and the beholder. Nature 1994;368(17):186–7.
Etcoff NL. A lei do mais belo. Rio de Janeiro, Brasil: Editora Objetiva;
1999.
Dufourmentel CY, Mouly R. Plastie mamaire par la methode oblique. Ann
Chir Plast 1961;6:45.
Elbaz JS, Werheecke G. La cicatrice em L. dans les plasties mamires. Ann
Chir Plast 1972;17:283.
Goldwyn RM. Plastic and Reconstructive Surgery of the Breast. Boston:
Little, Brown; 1976. p. 16.
Maliniac JW. Breast deformities. Anatomical and physiological consider­
ations in plastic repair. Am J Surg 1938;39:54.
Marchac D, De Oliarte G. Reduction mammaplasty and correction of
ptosis with a short infra-mammary scar. Plast Reconstr Surg
1982;69:45.
Livio M. La proporción áurea, la historia de PHI, el numero más sorpren­
dente del mondo. Barcelona: Editorial Ariel S.A.; 2005.
Marquardt SR. Marquardt Beauty Analysis (web site). Available from
(accessed 6 June 2012).
Meyer R, Kesselring V. Reduction mammaplasty with an L-shape suture
line. Plast Reconstr Surg 1975;55:139.
Ono E, et al. Análise da proporção áurea em indivíduos dolico, braqui e
mesofaciais, por meio de radiografias cefalométricas laterais. Revista
Odonto Ciência 2007;22(56):154–9.
Peixoto C. Reduction mammaplasty: A personal technique. Plast Reconstr
Surg 1980;65:217.
Pitanguy I. Mammaplastias. Rev Latinoam Cir Plast 1963;7:139.
Regnault PCL. Reduction mammaplasty by the B technique. In: Goldwyn
RM, editor. Plastic and Reconstruction Surgery of the Breast. Boston:
Little, Brown; 1976. p. 269–83.
Ribeiro L, Backer E. Mastoplastia con pediculo de seguridad. Rev Esp Cir
Plast 1973;6:223.
Strömbeck JO. Mammaplasty: Report of a new technique based on the
two pedicle procedure. Br J Plast Surg 1960–1961;13:79.

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© 2013 Elsevier Inc
Chapter 13 
Key Points
●
Breast reshaping after massive weight loss can be
achieved by applying concepts of parenchymal
reshaping and redistribution of autologous lateral chest
wall tissue into the breast mound.
●
Careful assessment of parenchymal volume, amount of
redundant skin envelope, and extent of lateral skin/fat
roll is necessary for planning the procedure.
Importantly, medial displacement of the nipples is a
common finding in the massive weight loss patient.
●
The spiral flap procedure uses adjoining lateral
thoracic and epigastric flaps. The de-epithelialized
lateral thoracic flap, supplied by intercostal trans-
serratus perforators, takes a spiral course to augment
the superior pole of the breast over the pectoralis
major muscle and is suture suspended to the third
costal cartilage. The de-epithelialized epigastric flap is
supplied by descending branches from the sixth
intercostal and flips up to augment the inferior pole of
the breast and is suture suspended to the fifth costal
cartilage.
●
The dermal suspension mastopexy involves
de-epithelialization of an extended Wise pattern with
elevation of medial and lateral fasciocutaneous flaps,
auto-augmentation using the lateral flap, suspension of
flaps to rib periosteum, and parenchymal reshaping by
plication of the broad dermal surface.
Breast reshaping after massive
weight loss
Autologous tissue techniques
J. Peter Rubin and Dennis J. Hurwitz
INTRODUCTION
Female breasts undergo dramatic changes after massive
weight loss (MWL), with volume loss, deflation of the
skin envelope, and ptosis. Poor tissue quality and loss of
esthetic units make the MWL breast not only difficult to
beautifully shape, but also prone to recurrent deformity.
Complicating the MWL breast deformity is the surrounding
loose skin of the arm, axilla, and torso. As an evolving
paradigm of mastopexy after weight loss, the surrounding
soft tissues can be repositioned to improve breast volume
and shape. This can be done in a coordinated manner with
other upper body contouring procedures.
Typically, the breasts flatten, sag and descend on the
chest. Superior pole fullness is almost nonexistent. The
breasts are displaced and broadened by descended infra­
mammary folds (IMF). The IMF descent progressively
increases from medial to lateral. The nipple–areola com­
plexes (NACs) are ptotic and usually distorted and medially
displaced. Surrounding the breasts are rolls of mid torso
skin shaped by transverse subcutaneous fascial adherences
to underlying muscular fascia. This manifests as charac­
teristic lateral rolls that obliterate the lateral curvature of
the breast and blend the breast seamlessly with the upper
torso.1
The strategy for correcting the breast deformity in the
MWL patient considers the degree of NAC ptosis, current
and desired breast volume and shape, skin quality and quan­
tity, descent of the IMF, neighboring skin deformity, extent
of available tissue excess for breast augmentation and sus­
pension, and prior breast surgery. In many MWL patients,
the breasts descend 1–4 cm on the chest. As the IMFs
approach the costal margins, women admit that they have
to uncomfortably pull up their brassieres to raise their
breasts. The surface of the posterior aspect of the breast on
the chest wall has been called a footprint, which is the
“foundation for the overlying three-dimensional structure
of the breast”.2 Blondeel et al further subdivide the perti­
nent breast esthetics into breast conus, skin envelope quality
and quantity.2 “The breast conus refers to the three-
dimensional shape, projection, and volume of the tissue (or
implant) on top and anterior to the footprint of the breast”.2
For additional online content visit

Part 3  Breast reshaping

123
Chapter | 13  Breast reshaping after massive weight loss
PREOPERATIVE PREPARATION
Autogenous breast reshaping is offered to MWL women
who desire body contouring. They are eligible as soon as 1
year after their bypass surgery, if their weight loss has been
stable for 4 months, and if there is no expectation for further
weight loss. A thorough review of their medical history, with
emphasis on the evolution of obesity-related comorbidities
is important. The patient must be under optimal manage­
ment of their remaining medical diseases with no acute
issues.23 Their nutritional status is evaluated and specific
mineral, vitamin and protein deficiencies corrected.24,25
Most patients are also started on high protein supplements
with a goal of 75–100 g of protein per day. Patients with
BMI between 25 kg/m2 and 30 kg/m2 are the best candi­
dates. Moderately obese patients with BMIs between 30 kg/
m2 and 35 kg/m2 are advised to attempt further weight loss
before surgery and may be at greater risk for wound healing
complications.26 Patients with severe obesity must lose
weight before they are candidates for complex body con­
touring procedures. All MWL patients should be counseled
on expected results and expectations balanced. Patients who
have obviously unrealistic goals should be deferred.
A thorough history of breast disease, as well as family
history of breast cancer, should be obtained and mammog­
raphy performed consistent with American Cancer Society
guidelines.
SURGICAL PROCEDURE
Spiral Flap of Hurwitz with Upper Body Lift
Wise pattern mastopexy with spiral flap augmentation inte­
grates breast reshaping with UBL.3,4 Fundamental to an
UBL is removal of the mid torso skin rolls and improved
contour. If appropriate, the secondary component of the
UBL is superior repositioning of the breast footprint and
IMF.
With the patient standing, the excess skin of the upper
abdomen is vigorously pushed superolateral. When all
excess skin is gathered – the abdominal skin is tight and
the umbilicus is pulled slightly cephalad – a mark is made
where the gathered abdominal skin meets the new IMF
position along the nipple line. With the tissues still sus­
pended, the new parasternal and anterior axillary line
attachments of the breasts are sighted and marked. The
gathered tissues are dropped. The curvilinear incision line
that serves both the reverse abdominoplasty and the new
IMF is then drawn. This line starts at the marked parasternal
breast attachment and descends to the upper abdominal
marked nipple line point and then ascends to the marked
point at the anterior axillary line. This line is similar to the
IMF incision line of the Wise pattern, except that it includes
all the redundant abdominal skin with the central breast
The determinate issues are volume, shape (breast conus),
the breast footprint, the severity of the deformity, the need
and acceptance of extensive incisions to correct the breast,
and the availability of neighboring tissue for augmentation
and suspension. The major goals are central projection and
superior fullness, appropriate nipple positioning, and three-
dimensional shaping that restores the lateral curvature of
the breast.
Two techniques are highlighted in this chapter: spiral
flap reshaping and dermal suspension mastopexy with
auto-augmentation. Both techniques can treat inadequate
breast volume with transposition of nearby soft tissue
excess.
In the spiral flap technique, excess skin and fat of the
epigastrium and lateral thorax are de-epithelialized in con­
tinuity with the central breast mound and appropriately
positioned, then tailored and buried under Wise pattern
flaps.3 The inevitable twisting and turning of this compound
flap led to the name “spiral flap”.4 The epigastric flap is an
inferior extension of the central breast pedicle nourished
through descending intercostal perforating vessels. The
lateral chest flap is a tongue-like lateral fasciocutaneous
extension of the central pedicle, similar to the lateral tho­
racic flap described by Holstrom in 1987 with confirmed
utility and safety.5–8 It is a fasciocutaneous flap based on
perforators through the serratus muscle. Borud based his
breast reshaping after MWL on this flap, which he referred
to as the intercostal arterial perforator (ICAP) flap.9 Closure
of the donor site removes the lateral chest and back
roll, usually leaving a tight transverse closure along the
bra line.
The dermal suspension mastopexy10–13 employs a well
vascularized central dermoglandular pedicle.14,15 A modifi­
cation of the traditional Wise pattern allows for the precise
control of the skin envelope and nipple position16 with an
extended lateral wing of the Wise pattern used to both
eliminate the lateral roll and convert the redundant tissue
to a fasciocutaneous flap that is transposed into the breast
mound. The dermal suspension techniques of Qiao, Frey,
Cerqueira and others lay the historical foundation for the
use of parenchymal suspension and extensive sculpting via
dermal plication and fixation to the chest wall.17–22 Holm­
strom’s lateral thoracodorsal transposition flap, as men­
tioned above, is the basis for auto-augmentation with
adjacent chest wall tissues.5 Medial fullness is achieved
via the elevation and manipulation of a medial breast flap.
Great control over both skin envelope and parenchymal
shape may be gained with this procedure.
Both of these techniques have the advantages of correct­
ing the severe breast deformities associated with weight and
using regional tissues to augment breast volume. The dis­
advantages include lengthy scars and longer operative time
compared with traditional mastopexy techniques.

123.e1
Chapter | 13  Breast reshaping after massive weight loss
The patient is turned supine. De-epithelialization of the
Wise pattern, which extends inferiorly onto the abdomen,
is again assisted by the electric dermatome. Completion of
de-epithelialization is free hand. The lateral, superior and
medial Wise pattern mastectomy type flaps are elevated
superficially for 4 to 6 centimeters. The incision along the
inferior margin of the extended Wise pattern is extended
down to the rectus muscular fascia from the parasternal
margin to the inferior incision of the lateral back flap. The
lateral flap incision of the Wise pattern is continued to the
upper incision of the lateral back flap. Mobilized by com­
pletion of the perimeter incisions, the most inferior portion
of the lateral thoracic flap is sharply elevated from the ser­
ratus muscle until the intercostal perforators are visualized.
The seventh and eighth rib perforators may be ligated.
Finding these landmarks aids in preserving other perfora­
tors to the lateral thoracic flap from the third through sixth
intercostals. Otherwise, the arterial pulsations between the
anterior and midaxillary line can be confirmed by Doppler
recordings.
Next, the lateral entry location for the lateral thoracic
flap to its superior breast pole submammary position is
started. Laterally, the lateral margin of the pectoralis muscle
is located over the fourth rib and supramuscular dissection
of the plane for the flap is made. Trying to avoid unneces­
sary trauma to the lateral thoracic artery blood supply,
grasping the skin and pectoralis muscle along the anterior
axillary line assists in identifying this plane. In addition an
incision is made along the superior margin of the
de-epithelialized new NAC site and continued to the pec­
toralis fascia. Then a pocket for the flap over the third rib
is developed from the lateral margin of the pectoralis to the
parasternal region. Finally, the medial dissection under the
medial Wise pattern flap is extended superiorly to the supe­
rior pole of the breast avoiding injury to the parasternal
internal mammary perforators.

124
PART | 3  Breast reshaping
pedicle. Obviously the reverse abdominoplasty, which
removes excess skin of the epigastrium which was not cor­
rected by prior abdominoplasty, can be performed without
changing the location of the IMF. The IMFs are the upper
line of excision of excess skin. The inferiorly based abdom­
inal flaps are discontinually undermined to the costal
margins. The closure ends along the newly designated
IMFs, and unless there is symmastia, it does not cross the
sternum. Occasionally, too much upper midline skin excess
remains and then an inverted “V” of skin is excised over
the xiphoid. The discontinuously undermined reverse
abdominoplasty flap will be advanced and suture secured
along the sixth rib (Fig. 13.1).
The drawing of the transverse incision lines around
the mid torso extends laterally from the reverse
abdominoplasty/Wise pattern mastopexy plan. For the bra
line excision, the IMF and lateral Wise pattern flap mark­
ings are continued parallel and posterior, to taper together
just beyond the tip of the scapula. The width between the
parallel incisions is as much tissue that can be pushed and
pinched together to take up all the back slack. Only in the
most severe cases does the excision cross the posterior
midline, because there is no lax skin over the spinal column
and scarring this area disrupts the valued contoured beauty
of the female mid back. Position the incision lines and
gauge the tension of closure to place the closure within the
posterior bra line.
In patients with less than severe back skin laxity or who
refuse a mid back scar, the long posterior flap extension of
the Wise pattern has been, over the past 5 years, turned
superior along the mid lateral chest to end at the axilla.
Often this excision is continued into an L-brachioplasty. To
capture mid lateral back rolls, the flap curves inferiorly,
forming a “J” shape. The entire operation can be performed
in the supine position. After harvest of this mid lateral chest
flap for breast augmentation, the J cut out back flap is suture
advanced to the anterior serratus muscular fascia. The
lateral breast is thereby bordered by tight chest wall con­
forming skin.27
After induction of general anesthesia, the operation
starts prone with the transverse bra line back roll excision/
donor site. Following infusion with epinephrine containing
saline, the bra line excision is de-epithelialized using an
electric dermatome set widest at 0.8  µm (32 000 of an
inch). After the perimeter incisions are made, the lateral
thoracic flap is raised from medial to lateral from the fascia
overlying the latissimus dorsi (L-D) muscle. Several centi­
meters before the anterior border of the L-D, the dissection
plane includes the muscle fascia and continues around the
L-D to the serratus muscle fascia. As the flap lies on the
OR table, the donor site is closed in two layers of absorb­
able barbed suture (#2 PDO and 2-0 Monoderm, Quill).
Skin glue seals the closure.
The vascularity of the lateral thoracic flap is confirmed
and then the inferior breast with its superiorly based epi­
gastric extension is elevated from its descended location
near the eighth rib to the sixth. Despite descended NACs,
this interruption of the inferior border of the breast has had
no NAC vascular compromise. That is because our breast
mobilization, Wise pattern thin skin flap elevation, and
positioning of the spiral flaps have not interrupted the criti­
cal transverse blood supply to the breast along the fourth
and fifth intercostal septum of the breast.13 We and others
have anatomically and clinically confirmed Wuringer’s
anatomical vision, making the distance of NAC elevation
during mastopexy essentially irrelevant as long as the mid
glandular septum is preserved.14
A sufficiently sized pocket has been created over
the pectoralis major muscle for positioning of the de-
epithelialized lateral thoracic flap within the superior pole
of the breast. Before the flap is placed, the descended breast
is dissected from its location over the seventh and eight
ribs with visual preservation of intercostal perforating
vessels. The reverse abdominoplasty subcutaneous fascia is
advanced to the sixth rib and serratus muscle with inter­
rupted large braided permanent sutures. The secure IMF
supports the higher breast footprint.
Then, the medially based lateral thoracic flap, which
remains attached to the central breast mound, is turned
cephalad along the anterior axillary line. After cutting the
distal tip to check for adequate blood supply, the flap is
tunneled into the superior pole pocket. The distal end
dermis and fat is sutured to the parasternal region about the
level of the third rib. Esthetic suture shaping is aided by the
exposure created by the recent addition of the superior pole
incision for exposure.
The mass of flap and breast tissue still sags laterally. To
centralize the mound, the breast inferior dermal pedicle is
advanced to the fifth intercostal cartilage and secured.
Together with the secured lateral thoracic flap a dermal flap
sling is created to provide superior to medial support. The
lateral breast contour is improved by suturing the trans­
posed flap to the lateral pectoralis major muscle. The
de-epithelialized flap and breast are tailored and imbricated
to optimally shape the breast. The tight closure of the lateral
thoracic flap donor site from the axilla to the IMF flattens
this lateral chest area to demarcate the newly created lateral
breast fullness, and breast projection. The lateral chest
donor site closure is continuous with the advanced and
stabilized new IMF.
The excess upper abdominal de-epithelialized flap is
usually flipped up and sutured to smoothly fill out the infe­
rior pole of the breast. Dermal imbrication of the
de-epithelialized breasts and the spiral flap forms the
desired contour. The Wise pattern skin flaps are closed to
each other and the new IMF. If the closure is too tight due

125
Chapter | 13  Breast reshaping after massive weight loss
FIG. 13.1  The J-shaped thoracoplasty modification of the spiral flap reshaping of the breasts. It is used when the back roll excess is primarily
lateral to the breast and a back scar is to be avoided. Closure of the lateral and inferior donor sites achieves an upper body lift with a raised inframam­
mary fold (IMF). (A) An extended Wise pattern de-epithelialization includes excess skin and adipose flaps lateral and inferior to the sagging and deflated
breasts. (B) Full thickness flaps continuous with the central breast mound are harvested on intercostal perforating vessels for augmentation and suspen­
sion of the empty superior and deficient inferior poles of the breast. The low lying breast is undermined from about the eighth rib to the sixth rib. The
upper abdominal skin is discontinuously undermined with LaRue dissectors to preserve trans-rectus abdominus perforators. (C) With care taken to
preserve the breast parenchyma vascularity through the fourth and fifth intercostal, internal mammary and lateral thoracic vessels, the inferior flap
extension is flipped up to augment the inferior pole and the J-shaped extension to the axilla spirals and advanced and sutured to the third rib costochon­
dral junction to fill the superior pole and suspend the breasts. Suturing the de-epithelialized inferior flaps to the sixth costochondral cartilage in conjunc­
tion with securing the superior flap medializes and projects the combined breast and spiral flaps. (D) Closure of the Wise pattern mastopexy repositions
the nipple–areola complex (NAC) and the skin flaps over the enlarged and suspended breast mound. The raised IMF is sutured along the sixth rib and
the advanced back flap is sutured to the serratus muscle along the anterior axillary line from the lateral IMF to the lower axilla.
A
B
C
D
A
B
C
D

125.e1
Chapter | 13  Breast reshaping after massive weight loss
The Wise pattern mastopexies, new IMF position,
reverse abdominoplasty, lateral thoracic and superior epi­
gastric flap harvests are planned together. The Wise pattern
should be drawn with narrow and long vertical limbs to
accommodate the autogenous fill. Also, the new NAC
should not be placed slightly above the original IMF regis­
tration, as it will descend slightly as the IMF is raised. The
preoperative markings begin with the patient sitting and
marking the sternal notch with a descending vertical refer­
ence line to the xiphoid. From the mid clavicles, descending
vertical reference lines are drawn through each NAC to the
IMF. The ptotic NACs are elevated, and the current IMFs
are sighted and drawn under each breast and then registered
over the sternum. Each breast footprint is raised an appro­
priate distance superiorly for best esthetic appearance, and
the new IMF position registered over the sternum. The
ptotic NAC is pushed superiorly along the midclavicular
line with the appropriately positioned nipple at the IMF
level or up to several centimeters superior to about the third
rib and marked on the skin and registered over the sternum.
The Wise pattern keyhole encircles the nipple mark with
8–10 cm long vertical limbs that are no further apart than
the width of the NAC.

126
PART | 3  Breast reshaping
to the soft tissue augmentation then further undermining of
the skin flaps may be necessary. Finally, the NAC is fitted
into the top of the keyhole pattern. The chest and breast
incisions are covered with skin glue, dressed in light gauze,
and a loosely applied surgical bra.
Usually, an L brachioplasty is performed concurrently.28
The short descending limb excision of the L may extend to
the bra line closure. The full width of lateral chest excision
awaits the breast closure, because the lateral chest laxity is
taken in by the autogenous enlargement of the breast. Clini­
cal examples are shown in Figs 13.2, 13.3, 13.4, 13.5, 13.6,
13.7, 13.8, 13.9, 13.10, 13.11 and 13.12.
FIG 13.7, 13.9, 13.10, 13.12 APPEARS ONLINE ONLY
Dermal Suspension Mastopexy of Rubin
with Auto-augmentation
The patient is marked standing. A midline sternal notch to
the xiphoid reference line is marked, followed by breast
meridian lines from mid clavicle that bisect the breast and
ignore the native nipple position if the nipples are abnor­
mally medialized. The nipple position is referenced to the
IMF along the newly marked breast meridian. A Wise
pattern is marked with 5 cm limbs and the lateral portion
of the Wise pattern is extended posteriorly to encompass
the axillary skin roll and provide additional autologous
tissue for breast volume (Figs 13.13–13.19). 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 augmen­
tation. The height of the lateral flap is determined by pinch
test. The lateral flap is generally limited in length to the
posterior axillary line, although skin resection to alleviate
the lateral skin roll may extend well beyond the portion of
the Wise pattern to be de-epithelialized. This flexibility in
design allows the surgeon to control the skin envelope and
titrate the amount of lateral tissue to mobilize to the breast.
The second and third ribs are marked.
Under general anesthesia, the patient is prepped in the
supine position with arms extended at approximately 70°
and secured to well-padded arm boards. The NAC is
marked with a 42 mm diameter ring and epinephrine
solution (1 : 100 000 is injected into the dermis within
the Wise pattern). The entire region within the Wise
pattern is sharply de-epithelialized. The breast paren­
chyma is then completely degloved by raising a tissue
flap off the breast capsule measuring 1 to 1.5 cm in thick­
ness. Once the edge of the breast parenchyma is reached,
undermining of the tissues continues over the pectoralis
major fascia to the level of the clavicle. This creates a
generous subcutaneous pocket into which the breast tissue
and adjacent lateral flap can be transposed. Medial and
FIG. 13.2  Before and 1 year after right anterior oblique views of an
L brachioplasty combined with a J thoracoplasty modified spiral flap
reshaping of the breasts with an upper body lift, reverse abdomino­
plasty and elevation of the IMF. (A) Patient is 39 years old, BMI of 28.7,
who lost 63 kg (139 pounds) 6 years after Roux-en-Y bypass. She had a
previous abdominoplasty. As this and subsequent views (Figs 13.3–13.5)
show, there is grade 3 ptosis with deflated and flat breasts, having no fill
of the superior poles. Most of her back roll is immediately lateral to her
breasts and will be incorporated into the J thoracoplasty for augmentation
and suspension of the superior pole as indicated in the preoperative draw­
ings on her body. The Wise pattern has 10 cm long vertical limbs to
accommodate the anticipated flap augmentation. The brachioplasty mark­
ings are freehand drawn hemi ellipses along the bicipital groove, which
then have measured equal distances confirmed from the elbow to the
deltopectoral groove and the elbow to the end of the advancement point
along the posterior border. (B) One year later, the entire breasts are higher
on the chest, greatly augmented and better shaped. The raised IMFs and
back skin are advanced superiorly and laterally to firmly frame the soft
and well-projecting breasts. The arms were significantly reduced in
volume and sag with a natural curved posterior border. The curving medial
scar ascends through the minimally concaved axilla and takes a right angle
turn below the deltopectoral groove to descend between the lateral breast
and chest wall.
A
B

126.e1
Chapter | 13  Breast reshaping after massive weight loss
FIG. 13.7  The posterior view shows moderate skin laxity of the back.
FIG. 13.9  Intraoperative view of the de-epithelialized breast, epigas­
tric and J-shaped lateral thoracic flaps.
FIG. 13.10  Intraoperative view of the anticipated positioning of the
flaps to form a breast mound. The lateral thoracic flap will be posi­
tioned over the superior pectoralis muscle where it is suture sus­
pended and shaped.
FIG. 13.12  Posterior view 3 months after the second stage.

127
Chapter | 13  Breast reshaping after massive weight loss
FIG. 13.3  Intraoperative supine right oblique views during the pre­
operative prep A and at the completion of the skin suturing B. (A) The
full extent of the de-epithelialization of the Wise pattern, and surrounding
inferior (across the sternum) and lateral flaps (up to the axilla) is shown.
The breast mound is collapsed with no fullness at her planned new NAC
location. Considerable excess tissue falls lateral to the breast. (B) The IMF
and J-shaped upper body lift are suture suspended along the IMFs and
lateral breasts. The breasts are well projecting away from the tight lateral
chest and upper abdomen. The arms are reduced in size with temporary
obliteration of the concavity of the right axilla.
A
B
the intended final position. A 1-0 braided permanent suture
is carefully secured to the periosteum of the selected rib
along the breast meridian (very important to set the correct
axis of the breast), and the edge of the dermis at the top of
the keyhole pattern is captured in a mattress fashion. A
second reinforcing suture is placed to secure the dermis to
the rib periosteum at this point of fixation, as well as at the
edge of the medial and lateral flaps as described below. The
lateral breast flap is then suspended and secured to the chest
wall by tacking to the rib periosteum. 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.
The medial breast flap is then suspended and secured to the
chest wall. As mentioned, two permanent sutures are used
to secure each of these three major points of fixation to the
rib periosteum. With the suspension points established,
parenchymal shaping by dermal placation is commenced.
The broad surface area of dermis is meticulously plicated
with running 2-0 braided absorbable sutures to adjust the
shape. The process starts laterally 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 IMF distance to
5 cm and increase projection by forcing parenchyma out of
the lower pole. It is important to note that this step is highly
versatile and there is no set pattern for the plication. The
artistic eye of the surgeon will guide this breast shaping
process, and the surgeon should be free to place multiple
rows of plication sutures and design any pattern necessary
to achieve the desired three-dimensional form. 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 symme­
try. After initial placement of plication sutures, a fine tuning
process follows in which additional interrupted and running
plication sutures are added to refine the shape and gain
symmetry. Sutures may be necessary to secure the lateral
breast flap to the lateral chest wall fascia. Constant redrap­
ing of the skin flap during the shaping process helps guide
adjustments to breast form. If the abdominal wall tissues
are very loose, a decision may be made to secure the super­
ficial fascial system (SFS) layer of the dissected edge of the
abdominal wall to the periosteum of the fifth rib and firmly
restore IMF position.
For closure, a half-buried mattress suture secures the
dermal edges at the “triple point” along the IMF. Intrader­
mal sutures are then used to complete the closure, and
suction drains placed in each lateral breast. If the areola is
not exactly with the keyhole and/or the nipple is pointing
lateral flaps of breast tissue are then mobilized by under­
mining. The lateral flap is raised off the serratus fascia
with an electric cautery. Care is taken to preserve signifi­
cant perforating vessels that enter the tissue flaps near the
base. The lateral flap is trimmed to desired size, as neces­
sary. The nipple is perfused by a healthy central pedicle
blood supply.
The next step is suspension of the central dermal exten­
sion to the chest wall. The choice of rib level for fixation
is made intraoperatively based on the distance between the
areola and the preserved dermis at the top of the keyhole
pattern (i.e., how the NAC position is affected by the height
of suspension). This is most often the second rib, but can
be dropped to the third rib if necessary. The suspension
starts by elevating the central dermal extension (areola to
keyhole) and should raise the level of the nipple close to

128
PART | 3  Breast reshaping
FIG. 13.4  These are right lateral upper torso views before and 1 year after the same patient in Figs 13.2 and 13.3 In (A) and (B) photos the
right arm and breast are sagging, with loose back skin immediately behind the breast. (C) The improvement is seen 1 year later. There is no
back scar, with the skin laxity of the flank unchanged.
A
B
C
in an inappropriate direction, the tethering dermis adjacent
to the areola is released with the electric cautery to
allow the NAC to shift into proper position. This step
is routinely performed, often with two thirds of the circum­
ference of the areola circumscribed. The robust central
pedicle blood supply makes that maneuver safe, and there
have been no cases of nipple loss with this procedure.
Pre- and postoperative results are shown in Figs 13.20A,
13.20B, 13.20C, D, 13.21A, B, 13.21C–E, 13.21F, 13.22A–
H and 13.22I.
FIG 13.20–22 APPEARS ONLINE ONLY
Figure 13.22 points out the fact that if this procedure is
performed concurrently with a fleur-de-lis abdominoplasty
and there is redundant skin at the superior pole of the
midline abdominal incision, then the scar should be allowed
to contract and the dog-ear excised electively. This will
reduce the ultimate scar length extending superiorly into
the midline chest.
OPTIMIZING OUTCOMES
1. A two team approach to the operation increases
efficiency.
2. For the spiral flap procedure, reserve lateral and medial
blood supply to the breast at the third, fourth and fifth
intercostals.
3. For the dermal suspension mastopexy, extend the Wise
pattern as far laterally as is necessary to eliminate the
skin rolls. The entire lateral “wing” of the Wise pattern
may be de-epithelialized and preserved to add volume
to the breast, as needed. Conversely, a smaller portion
may be preserved and the remainder excised.
4. Exercise caution when considering smokers for these
procedures because of the risk of flap necrosis.
POSTOPERATIVE CARE
Light compression dressings are placed, either in the form
of a surgical bra with gauze sponges, or as an elastic wrap.
Overnight observation is recommended for multiple body
contouring procedures and as indicated for the patient’s
medical status. Intake and output are closely monitored, and
Hgb/Hct measured as needed. Pain relief, by patient con­
trolled analgesia (PCA) through a push button IV, is usually
satisfactory. Intermittent calf pressure stockings are used
until resuming frequent ambulation. Closed suction drains
are removed when output is less than 30 ml in 24 hours.
An active scar treatment program with a variety of modali­
ties is essential. If the scars fail to regress after 8 weeks,
we start a graded program with paper tape, silicone sheeting,
microdermabrasion, Retin-A, and intense pulsed light.
Adrucil (5-fluorouracil) injections are occasionally used.29
COMPLICATIONS
For the spiral flap procedure, in about 20% of cases there
is palpable distal flap induration, suggestive of necrosis.30

128.e1
Chapter | 13  Breast reshaping after massive weight loss
FIG. 13.20  (B) Suspension of the central dermal extension
bilaterally.
B

128.e2
PART | 3  Breast reshaping
FIG. 13.21  A 46-year-old patient treated with this mastopexy technique following a 160-lb (73kg) weight loss. (C and E) Preoperative and (D)
6-month postoperative views. (From JP Rubin & A Matarasso, Approach to the breast after weight loss. In: Aesthetic Surgery after Massive Weight
Loss. Philadelphia: Saunders; 2007.)
C
D
E

128.e3
Chapter | 13  Breast reshaping after massive weight loss
FIG. 13.22  Correcting the superior dog-ear at the first surgery
would have resulted in a longer scar extending onto the midline.
Patient is shown 7 months after mastopexy and abdominoplasty (I).
I

129
Chapter | 13  Breast reshaping after massive weight loss
FIG. 13.5  These are the before and 1 year after frontal views of the
upper torso and arms of the patient shown in the previous figure. The
artistic correction of the arms, chest rolls and breasts is maintained.
The arms are proportional to the torso. The axillary hollows are natural.
The breasts are raised with the superior and inferior poles full. NACs have
remained at the level of the medial IMF attachment.
A
B
FIG. 13.6  Pre-, intra- and postoperative photographs of a two-stage
total body lift that includes a J torsoplasty in a 39-year-old massive
weight loss patient with a BMI of 27. Preoperative right oblique view
showing her to have unusually large mid torso rolls and hips, sagging
thighs and small ptotic breasts.
Most areas of firmness resolve over time, leaving limited
delayed debridement. One patient had operative debride­
ment of the distal 50% of the flaps followed by insertion of
saline-filled silicone implants. The posterior scars extending
on to the back may be hypertrophic and require revision.
The most common esthetic shortcomings of the spiral flap
reshaping of the breasts are superior pole induration and
depression, and lateral breast bulges. A year or so of patience
will allow for absorption of distal flap necrosis; however,
debridement may be indicated for more extensive necrosis.
Following those treatments and when there is a gap between
the superior breast and the tunnels flap, limited lipoaugmen­
tation through fat injections has been successful. The lower
portions of these reshaped breasts can be excessively broad
due to the base of the lateral thoracic pedicle. After 6
months, direct excision of these lateral bulges and narrow­
ing of the base of the breasts is effective and safe.
With the dermal suspension technique, fat necrosis is
uncommon in over 100 cases because the lateral flap length
is limited. Minor wound separation has been seen in
approximately 5% of cases and no nipple necrosis or slough
has been observed. Hypertrophic or widened scars have
been revised in less than 5% of patients. Lateral or superior
dog-ears have been revised in less than 7% of patients.
CONCLUSIONS
Breast reshaping techniques that move adjacent tissue into
the breast mound and focus on parenchymal shaping are
highly effective at achieving an esthetic breast appearance
after massive weight loss. Moreover, adjacent anatomic
regions can be contoured simultaneously and synergisti­
cally. These techniques require careful analysis of the breast
deformities and surrounding tissues. While longer operative
times are required compared to traditional mastopexy tech­
niques, the procedures described here are highly versatile
and have a powerful impact.
Text continued on page 137

130
PART | 3  Breast reshaping
FIG. 13.8  Three months after a first stage inverted T abdomino­
plasty, lower body lift and vertical medial thighplasty, she is marked
for her second stage. She will have bilateral L brachioplasties, J tor­
soplasty upper body lifts, and spiral flap reshaping of the breasts.
FIG. 13.11  Right oblique view 3 months after her second stage and
6 months after the first.
FIG. 13.13  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 de-epithelialized, preserving an extensive dermal surface. The entire axillary roll or only part of it can be used for autologous volume
augmentation.
A
B
Breast marked
with Wise pattern
Entire Wise pattern
de-epithelized
Lateral Wise extension
dependent upon amount
of skin roll and/or size
of lateral flap desired
Extent of de-epithelization is dependent upon size
of flap used for volume augmentation and need
not include entire Wise pattern

131
Chapter | 13  Breast reshaping after massive weight loss
FIG. 13.14  The breast parenchyma is degloved by raising a 1 cm thick flap. Medial and lateral flaps of dermis/breast tissue are mobilized
from the chest wall.
Pocket undermined
1cm thick flap elevated
Pectoralis fascia
Lateral dermal/breast
parenchymal flap elevated
Medial dermal/breast
parenchymal flap elevated
Midline suture purchases
rib periosteum
Central dermal extension
Lateral breast flap
FIG. 13.15  The central dermal extension is elevated and secured to the chest wall rib periosteum using braided nylon sutures. Most often, the
second rib is used, but this can vary based on the patient’s anatomy.

132
PART | 3  Breast reshaping
FIG. 13.16  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. 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. The dermis of the medial breast flap is approximated to the central dermal extension
using a running suture.
Areas to be plicated
Lateral flap secured to chest wall
Medial flap secured to chest wall
and dermal plication initiated
FIG. 13.17  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. Additional “fine tuning” plication sutures are added to further adjust shape, as needed.
Lateral flap
Medial flap

133
Chapter | 13  Breast reshaping after massive weight loss
Dermis of lateral flap
sutured to fascia on
chest wall
FIG. 13.19  The dermis surrounding the nipple is scored along part of the circumference, as necessary, to allow the nipple to point forward.
The breast skin flap is redraped and closed with absorbable intradermal sutures over a drain.
FIG. 13.18  The lateral breast flap dermis sutured to the chest wall fascia to keep the breast parenchyma from bulging laterally and further
increase projection.

134
PART | 3  Breast reshaping
FIG. 13.20  (A) Intraoperative photographs showing extensive de-epithelialization. (C) Plication sutures in place. (D) Redraping of skin flap.
Pre- and postoperative photographs of this patient are shown in Fig. 13.21. (From JP Rubin & A Matarasso, Approach to the breast after weight
loss. In: Aesthetic Surgery after Massive Weight Loss. Philadelphia: Saunders; 2007.)
A
C
D

135
Chapter | 13  Breast reshaping after massive weight loss
FIG. 13.21  A 46-year-old patient treated with this mastopexy technique following a 160 lb (73kg) weight loss. (A) Preoperative and (B, and F)
6-month postoperative views. (From JP Rubin & A Matarasso, Approach to the breast after weight loss. In: Aesthetic Surgery after Massive Weight
Loss. Philadelphia: Saunders; 2007.)
A
B
F

136
PART | 3  Breast reshaping
A
B
C
D
FIG. 13.22  A 46-year-old woman following massive weight loss marked for dermal suspension mastopexy and concurrent fleur-de-lis abdomi­
noplasty (A, B, C), Patient is shown at 4 months after mastopexy and abdominoplasty, with dog-ear at superior pole of abdominoplasty marked
for planned elective excision (D, E, F). Correcting the superior dog-ear at the first surgery would have resulted in a longer scar extending onto
the midline. Patient is shown 7 months after mastopexy and abdominoplasty (G, H).

137
Chapter | 13  Breast reshaping after massive weight loss
E
F
G
H
FIG. 13.22  Continued
REFERENCES
1. Song AY, Jean RD, Hurwitz DJ, et al. A classification of contour
deformities after bariatric weight lost: The Pittsburgh Rating Scale.
Plastic Reconstr. Surg 2005;116(5):1535–44.
2. Blondeel PN, Hijjawi J, Depypere H, et al. Shaping the breast in
aesthetic and reconstructive breast surgery: an easy three-step prin­
ciple. Plast Reconstr Surg 2009;123:455–62.
3. Hurwitz DJ, Golla D. Breast reshaping after massive weight loss.
Semin Plast Surg 2004;18:179–87.
4. Hurwitz DJ, Agha-Mohammadi S. Post bariatric surgery breast
reshaping: the spiral flap. Ann Plast Surg 2006;56:481–6.
5. Holmstrom H, Lossing C. The lateral thoracodorsal flap in breast
reconstruction. Plast Reconstr Surg 1986;77:933–41.
6. Woerdeman LAE, van Schijndel AW, Hage JJ, et al. Verifying surgi­
cal results and risk factors of the lateral thoracic flap. Plast Reconstr
Surg 2004;113:196–203.
7. Levine JI, Soucid NE, Allen RJ. Algorithm for autologous breast
reconstruction for partial mastectomy defects. Plast Reconstr Surg
2005;116:762–6.
8. Van Landuyt K, Hamdi M, Blondeel P, et al. Autologous augmenta­
tion of pedicled perforator flaps. Ann Plast Surg 2004;53(4):322–7.
9. Kwei S, Borud LJ, Lee BT. Mastopexy with autologous augmenta­
tion after MWL: The intercostal artery perforator (ICAP) flap. Ann
Plast Surg 2006;57:361–7.
10. Rubin JP, Gusenoff JA, Coon D. Dermal suspension and parenchy­
mal reshaping mastopexy after massive weight loss: statistical analy­
sis with concomitant procedures from a prospective registry. Plast
Reconstr Surg 2009;123(3):782–9.
11. Rubin JP. Mastopexy in the massive weight loss patient: dermal
suspension and total parenchymal reshaping. Aesth Surg J 2006;
26:214–22.
12. Rubin JP, Khachi G. Mastopexy in the massive weight loss patient.
Clin Plast Surg 2008;35:123–9.

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24. Agha-Mohammadi S, Hurwitz DJ. Nutritional deficiency of post-
bariatric body contouring patients: what every plastic surgeon should
know. Plast Reconstr Surg 2008;122:604–13.
25. Agha-Mohammadi S, Hurwitz DJ. Potential impacts of nutritional
deficiency of post-bariatric patients on body contouring. Plast
Reconstr Surg 2008;122:1901–14.
26. Hurwitz DJ, Wooten A. Plastic surgery for the obese. Int J Adipose
Tissue 2007;1:5–11.
27. Clavijo-Alvarez J, Hurwitz DJ. “J” torsoplasty. A novel approach to
avoid circumferential scars of the upper body lift. Plast Reconstr
Surg 2012; in press.
28. Hurwitz DJ, Holland SW. The L brachioplasty: An innovative
approach to correct excess tissue of the upper arm, axilla and lateral
chest. Plast Reconstr Surg 2006;117(2):403–11.
29. Davison SP, Dayan JH, Clemens MW. Efficacy of intralesional
5-fluorouracil and triamcinolone in the treatment of keloids. Aesth
Surg J 2009;1:40–6.
30. Hurwitz DJ, Agha-Mohammadi S, Ota K, et al. A clinical review of
total body lift. Aesth Surg J 2008;28(3):294–304.
Fig. 13.7, 13.9, 13.10, 13.12, 13.20–22 can be found online.
Bonus images for this chapter can be found online at

13. Rubin JP, O’Toole J, Agha S. Breast surgery after weight loss. In:
Rubin JP, Matarasso AM, editors. Aesthetic Surgery after Massive
Weight Loss. London: Elsevier; 2006.
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Chir 1928;55:2382–7.
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maplasty. Plast Reconstr Surg 1956;17:365–70.
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tion mammaplasty. Plast Reconstr Surg 2002;109:2289–300,
18. Goes J. Periareolar mammaplasty with mixed mesh support: The
double skin technique. Oper Techn Plast Recon Surg 1996;3:197–9.
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20. Frey M. A new technique of reduction mammaplasty: dermis suspen­
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45–51.
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of ptosis: dermal bra technique. Plast Reconstr Surg 2003;111:
1122–30.
22. Gulyas G. Mammaplasty with a periareolar dermal cloak for glan­
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© 2013 Elsevier Inc
Chapter 14 
Key Points
●
Staging may be appropriate for extremely large or
ptotic patients.
●
The circumvertical approach is a powerful tool for
management of the redundant skin envelope.
●
Controlled management of the IMF is key to reducing
the number of later revisions.
●
Use of an implant can be an excellent adjunct for
restoring upper pole fullness.
●
Patient education regarding the complex and in some
ways potentially imperfect nature of the surgical
correction can aid in helping patients understand the
potential need for future revisions to obtain the
optimal result.
Breast reshaping after massive weight loss,
implant based
Dennis C. Hammond, Shannon D. Armstrong and Michael Loffredo
INTRODUCTION
Since its development in 1966, bariatric surgery has become
an effective modality for sustained weight loss. The growth
of bariatric surgery has paralleled the burgeoning obesity
epidemic in the United States.1 Roux-en-Y gastric bypass
has become the most effective and frequently performed
means of sustained surgical weight loss, with mean weight
loss at 36 months of 41 kg.2,3 Other surgical procedures
include biliopancreatic diversion, adjustable gastric
banding, and the creation of a gastric sleeve.4–6 Addition­
ally, some patients are able to achieve weight loss with diet
and exercise alone. Regardless of the means of weight loss,
massive weight loss (MWL) is defined as weight loss of
45 kg (100 pounds) or more.7
Weight loss causes a multitude of both physiologic
and anatomic changes. Severe volume loss results in skin
redundancy and sagging, which can lead to issues with
hygiene and the potential for infection. Song et al elegantly
rated the anatomic changes that occur throughout the integ­
umentary system after MWL.8 Additional consideration
must be given to the nutritional status of MWL patients.
Appropriate preoperative laboratory testing as well as
consultation with a nutritionist may be advisable in these
types of patients. The psychiatric changes that accompany
MWL, and patient motivation for body contouring must
also be considered when dealing with MWL patients.9–13
After MWL the breast undergoes a unique set of changes
not typically seen in other settings. The breast becomes
deflated with a paucity of upper pole tissue. Extreme ptosis
of the skin envelope and the nipple can develop, along with
inferior malposition of the inframammary fold (IMF). The
total amount of volume loss is variable among patients. The
nipple areolar complex also often becomes displaced medi­
ally. The breast mound itself can be displaced laterally
and the chest wall can take on an almost barrel-shaped
configuration. Additionally, the skin envelope can become
inelastic14–16 (Fig. 14.1A–D). All these anatomic changes
serve to make augmentation mastopexy, an already chal­
lenging procedure, even more intimidating.
Surgical restoration of the breast in these types of
patients includes elevating and lateralizing the nipple–
areola complex (NAC), elevating the IMF, restoring upper
pole volume, and narrowing the wide breast. Additionally,
excess axillary tissue should be excised when present to
help better define the lateral border of the breast and aid in
reducing fullness when the patient is wearing a brassiere.
The breast implant is a powerful tool that can aid in
restoring volume to the deflated breast as well as
re-establishing upper pole fullness for these patients.
However, thoughtful surgical planning must be undertaken
when using implants in the MWL patient. Conservative
implant size should be considered, as MWL patients have
unstable skin envelopes and may have recurrent ptosis if
large implants are used. Some have advocated staging pro­
cedures for patients with severe ptosis to avoid potential
complications such as compromise of nipple vascularity,
and also to improve the predictability of the operation.
Staging the procedure is a reasonable option for these
patients; however, the cost must be factored into the deci­
sion, especially given that these patients often require revi­
sionary surgery regardless of the approach used.
Part 3  Breast reshaping

140
PART | 3  Breast reshaping
plastic surgical procedure. This usually occurs 12–18
months following the weight loss surgery.17
Preoperative assessment of the MWL patient must
include a full evaluation of the patient’s nutritional status.
This is especially important in patients who have under­
gone diversionary procedures, and to a lesser extent those
undergoing restrictive procedures. MWL patients that
were able to lose weight through diet and exercise gener­
ally have adequate nutrition and do not need supplementa­
tion. Whether or not supplemental Vitamin B12, iron,
calcium, and/or multivitamins are being used should be
noted, as deficiencies here can lead to altered wound
healing. Baseline laboratory values should consist of a
complete blood count, electrolytes, prothrombin/partial
thromboplastin time, and albumin levels.7 Micronutrients
may also need to be assessed in selected cases of possible
malnutrition.18–20
Physical examination of the MWL patient should focus
on the quality of the skin, position of the inframammary
fold (IMF), degree of NAC ptosis, the amount of gland
remaining, and the quantity of axillary and lateral chest wall
soft tissue excess. Often these patients have stretched out
Overall, the breast deformity that can occur in MWL
patients is extremely variable and challenging. The com­
bination of parenchymal reshaping, strategically chosen
skin patterns and volume restoration using a breast
implant can be a useful tool set to address the entire
deformity. Prior to any surgical procedure, preoperative
preparation is essential to optimize outcome and ensure
patient safety.
PREOPERATIVE PREPARATION
Proper assessment of the MWL patient begins with ascer­
taining the method of weight loss. If the patient lost weight
through surgical means then determining whether the pro­
cedure was restrictive, diversionary or both allows the
surgeon to determine what nutritional workup is necessary.
Timing of the bariatric procedure and the starting weight at
the time of surgery, the amount of weight loss since the
procedure, the weight change in the past 3–6 months, and
how long the patient has been at the current weight should
all be ascertained. Generally, the patient should be at a
stable goal weight for 3–6 months or more prior to any
FIG. 14.1  (A–D) After massive weight loss the appearance of the breast can be quite variable. Common findings on physical exam include a
deflated and underfilled skin envelope, ptosis of the breast footprint, gland and NAC, unesthetic spreading of the areola, and medial transloca­
tion of the NAC.
A
B
C
D

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Chapter | 14  Breast reshaping after massive weight loss, implant based
Nipple viability and potential nipple loss must be part
included as a potential risk during augmentation masto­
pexy. Establishing realistic expectations and goals for sur­
gical outcome is an important part of a successful
augmentation mastopexy procedure.
PREOPERATIVE PLANNING – PRIMARY
AUGMENTATION MAMMAPLASTY
Incision
Access to breast is generally provided by the incisions used
to accomplish management of the redundant skin envelope.
For periareolar approaches, this includes the inferior half
of the periareolar incision. For circumvertical approaches,
access is obtained through the vertical component between
the bottom of the areola and the IMF. In either instance,
access to either a subglandular or subpectoral pocket is
readily obtained to allow accurate pocket dissection and
placement of the implant.
Pocket
For many patients, the anatomic footprint of the breast has
descended so far inferiorly that any attempt to create a
subpectoral pocket will simply serve to cover only a small
portion of the upper portion of the device secondary to the
inferior breast malposition below the normally positioned
pectoralis major muscle. In these circumstances, only minor
advantage is afforded by attempting to position an implant
under the muscle. For this reason, the subglandular plane
can be an attractive option for these types of patients. The
pocket dissection can be easily controlled and by removing
the complicating interaction of the released pectoralis major
muscle from its attachments to the overlying breast, one
more variable potentially affecting the final result is elimi­
nated, resulting in a simpler procedure. Also, by the time
the ptotic breast is tightened and repositioned superiorly,
the peripheral margins of the breast become softened,
allowing the subglandular position to be used without
risking undesirable implant show peripherally and in par­
ticular along the superomedial border. The potential for
breast animation is also eliminated by using the subglandu­
lar position. These advantages must be balanced against the
desire to avoid interference with postoperative mammo­
graphic evaluation of the breast and, as well, the risk for
capsular contracture must always be taken into consider­
ation. For patients who do not have a significant inferior
malposition of the breast footprint, the partial subpectoral
position with variable release of the inferomedial aspect of
the muscle can be used, as would be done in any other
breast augmentation procedure.
and inelastic skin with prominent striae that can create dif­
ficulties in shaping, wound healing, and maintenance of a
long-term result. The degree of ptosis and the distance the
NAC must be moved are considerations when an implant
is used, as this variable can affect the vascularity of the
NAC, particularly when an implant is placed under the
breast. The existing amount of breast tissue must be taken
into account when choosing an implant as this can affect
the final volume of the breast. Often, despite the fact that a
massive amount of weight has been shed, by the time the
breast is lifted, there is a significant amount of tissue that
can contribute to the overall breast volume. This must be
recognized to avoid choosing an implant that is too big.
The position of the IMF is one of the most important
issues in the MWL patient. The IMF is usually inferiorly
displaced due to the weight applied to the fold when the
patient is obese. This leads to the stretch of the chest wall
attachments, and once the patient loses weight the deflated
breast and IMF appear to have descended down the chest
wall. Management of the IMF is one of the most difficult
and potentially useful techniques in breast surgery of the
MWL patient, if performed well.
Axillary and lateral chest wall soft tissue redundancy
can be due to redundant skin and residual adiposity. Due
to the poor skin quality and the excess tissue, recontouring
this area is often best accomplished by direct resection.
When performing resection it is important to consider future
surgery the patient may have, such as brachioplasty and
upper body lift. Additionally, control of the lateral breast
pocket along the anterior axillary line must be respected
during this resection. Loss of control laterally could lead to
decreased patient satisfaction and increased likelihood of
revision due to lateral implant malposition.
Mastopexy in the MWL patient is a technically chal­
lenging procedure and augmentation mastopexy adds an
additional element of complexity. For surgeons not com­
fortable with augmentation mastopexy in MWL patients it
is certainly reasonable to stage the operation. Generally, the
mastopexy is performed first and the augmentation added
at a later date. Occasionally, the patient may not even seek
augmentation once the mastopexy has been performed.
Regardless, it is important to discuss potential costs involved
with the staged procedure.
Discussion of potential need for revision at the initial
consultation helps mitigate some of the later issues that may
arise when enhancements of the initial procedure are
needed. Meticulous documentation of conversations regard­
ing revisions is also important during the initial visit.
Informing patients that scar length is commensurate with
the amount of soft tissue resection allows the patient insight
into the outcomes of the procedure. Additionally, discus­
sion of recurrent ptosis, or the possibility of breast asym­
metry is important in the augmentation mastopexy patient.14

142
PART | 3  Breast reshaping
shape. For periareolar approaches, the proposed periareo­
lar opening is stapled down according to the preoperative
marks. For circumvertical approaches, the vertical incision
is plicated together until the desired lower pole contour is
created and then the periareolar portion is added. With the
patient upright on the operating table, the shape and sym­
metry of the result is assessed (Fig. 14.5). Further plication
or lifting is performed as needed to create the desired
result. The patient is laid back down and the plicated edges
are marked with a surgical pen and the staples are removed
(Fig. 14.6A, B). With the areola under maximal stretch, a
40 mm areolar outline is marked with the aid of a circular
template (Fig. 14.7). The areolar and periareolar incisions
are made extending just into the superficial dermis and the
redundant skin outlined by the marks is de-epithelialized
along the periareolar and vertical segments (Fig. 14.8).
The dermis around the periareolar incision is divided
5 mm away from the incised skin edge to create a small
dermal shelf that will eventually hold the purse string
suture. The edges of this shelf are undermined slightly to
allow a contoured periareolar closure to be accomplished
without excessive tissue bunching around the incision
Implant
It must be realized that MWL patients have a very loose
breast skin envelope and accurate pocket dissection can be
challenging. Despite what appears to be very conservative
pocket development, overdissection can very often be the
end result. For this reason, it is recommended that round
implants be used in an attempt to limit the potential for
implant rotation that can be associated with anatomically
shaped saline or cohesive silicone gel implants. Such
devices can be used; however, great care must be taken in
positioning and securing these implants into position. Uti­
lizing round implants eliminates the potential for this
complication to develop. Beyond this, all of the same con­
siderations regarding the advantages and disadvantages of
smooth versus textured devices as well as saline versus
silicone gel implants are just as pertinent in the augmentation/
mastopexy patient as they are in the primary augmentation
patient. It is left to each surgeon to factor these variables
into the decision making process to identify the best
approach for each individual patient.
SURGICAL TECHNIQUE
Primary Augmentation Mammaplasty
The patient is marked in the standing position with her arms
resting gently at her sides (Fig. 14.2A, B). Basic landmarks
including the IMF, midsternal line, and breast meridian are
marked. The IMF line is communicated across the midline
to allow the level of the fold to be identified without the
need to manipulate the breast. In the midline, measuring up
from the IMF, a distance of 4–6 cm is measured and this
point is then transposed in a parallel line over to each breast
meridian. This point represents the top of the periareolar
pattern. Extending inferiorly, an oval is then drawn around
the medial, lateral, and inferior aspect of the existing areola
to complete the periareolar pattern. In the vast majority of
cases, a vertical skin takeout will also be required to appro­
priately reduce the redundant skin envelope and lift the
breast. The amount of skin to be resected can be estimated
by pinching the inferior aspect of the breast below the NAC
together until a pleasing shape is created. The medial and
lateral aspects of the skin pinch are marked and carried
down to the IMF, curving laterally as needed to create a
contoured closure (Fig. 14.3A, B).
At surgery, the procedure is begun by accessing it
through either the periareolar or vertical incision and the
desired pocket is created, with care being taken to preserve
the attachments of the IMF and avoid disruption of the
dominant second intercostal perforator in the superomedial
portion of the breast (Fig. 14.4). An implant sizer is then
placed to create the desired volume. The skin envelope is
then plicated together with staples to create the desired
FIG. 14.2  Preoperative appearance of a 52-year-old woman in prep­
aration for augmentation mastopexy after losing 45 kg (100 lbs) fol­
lowing gastric bypass.
A
B

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Chapter | 14  Breast reshaping after massive weight loss, implant based
FIG. 14.3  Final marks showing the top of the periareolar pattern
being positioned a full 6 cm above the inframammary fold line seen
extending across the torso from side to side. The proposed vertical
takeout is noted to curve slightly laterally as it extends down to the infra­
mammary fold. This maneuver prevents bunching and potential wound
healing problems from occurring at the level of the IMF after final closure.
The exact dimensions of the vertical excision will be determined intraop­
eratively once the final implant is in place.
A
B
FIG. 14.4  Care is taken to preserve the attachments of the inframa­
mmary fold both medially and laterally to prevent inferior implant
malposition postoperatively.
FIG. 14.5  Appearance after both sides have been plicated. A 275 cm3
moderate profile plus sizer has been placed in the left breast and a
300 cm3 sizer on the right in an attempt to correct the patient’s pre­
operative volume asymmetry.
FIG. 14.6  (A) The plicated edges of the proposed vertical incision are
marked with a surgical pen. (B) With the staples removed, the final dimen­
sions of the vertical takeout can be seen. The access incision for pocket
dissection falls within this vertical segment.
A
B

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PART | 3  Breast reshaping
FIG. 14.8  The periareolar and vertical segments are de-epithelialized.
FIG. 14.9  The dermis around the periareolar incision is divided,
leaving behind a 5 mm dermal shelf into which the purse string suture
will be placed.
A
B
FIG. 14.10  Appearance of the breast mound after closure of the
vertical segment.
FIG. 14.7  With the aid of a circular template, a 40 mm diameter
areolar mark is made centered on the nipple.
(Fig. 14.9A, B). With the skin and parenchyma now com­
pletely prepared for final closure, the chosen implant is
inserted into the pocket. An iodoform occlusive drape is
applied to the skin, with a small opening being made in the
area of the skin incision. This prevents the implant from
contacting the skin during insertion, thus minimizing the
potential for bacterial contamination of the implant or the
pocket. In circumvertical cases, the vertical segment is
now closed (Fig. 14.10). The periareolar defect is managed
using the interlocking Teflon suture technique.21 A PTFE
suture on a straight needle is passed, joining eight evenly
spaced points in both the areolar and periareolar incisions,
spanning the intervening areas on the periareolar side by
passing the suture in the dermal shelf. Pulling this smooth,
strong and permanent suture together in a secure purse
string type fashion allows control of the size and shape of
the periareolar defect (Fig. 14.11A–C). A little trimming of
the de-epithelialized edges to create a perfectly round
shape with the final suturing completes the procedure22–27
(Figs 14.12 and 14.13).

145
Chapter | 14  Breast reshaping after massive weight loss, implant based
FIG. 14.12  Final immediate postoperative appearance.
FIG. 14.11  (A) A Teflon, polytetrafluorethylene (PTFE) suture attached to straight needle is used to control the periareolar defect. This material
is strong, permanent, and smoothly slides through the tissues without catching or bunching. (B) The suture is passed in such a way as to approximate
the 8 cardinal points of the areolar and periareolar incisions. (C) Appearance of the periareolar defect after the purse string suture has been cinched
down.
A
B
C
Surgical Technique – Staged
Augmentation Mammaplasty
The MWL patient has damaged skin and parenchyma com­
pared to a patient with a more proportionate body habitus.
As a result, after the weight loss has occurred, the deflated
breast is very prone to all manner of complications after the
placement of an implant and tightening of the skin enve­
lope. The severity of these complications seems to be
directly proportionate to the amount of weight loss and the
effect the weight loss has had on the breast. For this reason,
many surgeons believe that staging the mastopexy with the
augmentation is indicated to limit the incidence of compli­
cations and maximize the esthetic quality of the result. The
advantages of this approach include being able to better
judge how these two operations with differing goals can be
effectively combined in the best way possible.
Typically, when the surgeries are staged, the mastopexy
is performed first using the same periareolar or vertical
approaches described earlier. This allows the surgeon to

146
PART | 3  Breast reshaping
FIG. 14.13  Early postoperative appearance of the patient after the
placement of a 275 cm3 moderate profile plus smooth round sili­
cone gel implant on the left and a 300 cm3 implant on the right.
The circumvertical skin pattern has been applied to good effect, lifting
the NAC and tightening the skin envelope to create a pleasing breast
shape.
A
B
FIG. 14.14  (A) Preoperative appearance of a 45-year-old woman in
preparation for completion of a staged augmentation mastopexy. She has
previously undergone breast reduction followed by the loss of a significant
amount of weight resulting in an underfilled and ptotic breast. (B) Final
result.
A
B
OPTIMIZING OUTCOMES
● Liberal use of the circumvertical pattern.
● Areolar control using the interlocking technique.
● Intraoperative use of tailor tacking to create the desired
result.
● Conservative implant size.
● Simple implants (round versus anatomic).
POSTOPERATIVE CARE
Patients are placed in a well-fitted surgical bra immediately
after the surgery and drains are used only rarely. With
occlusive dressings in place patients may shower beginning
on postoperative day 1 and are instructed to refrain from
lifting anything over 4.5 kg (10 pounds) for 4 weeks. They
are also instructed to refrain from vigorous exercise for 6
weeks. The initial dressings are changed at the 1 week
raise the NAC, reshape the breast, and reduce the breast
skin envelope. Once the mastopexy is performed, the
patient is allowed to heal and after a minimum of 6 months
the surgeon can decide, now with fewer variables to deal
with, which implant size and placement would provide the
best esthetic result (Fig. 14.14A, B). The advantage of
staging is that fewer variables are addressed at each proce­
dure, thereby allowing greater accuracy with fewer compli­
cations. The disadvantage of the staged approach is that it
is more costly, as two procedures are always planned as
opposed to one in the combined approach. And in the case
of needing to treat a complication, even a third procedure
could well be required, all of which presents as a significant
financial challenge for many patients. Additionally, when a
combined approach does require revision, typically the
revision is of a less demanding nature as opposed to a
staged procedure where many of the same variables present
challenges for each planned procedure.

147
Chapter | 14  Breast reshaping after massive weight loss, implant based
FIG. 14.15  (A) Preoperative appearance of a 33-year-old woman in preparation for augmentation mastopexy after MWL. (B) Preoperative marks
demonstrating the proposed circumvertical pattern. (C) 8 month postoperative result demonstrating a mild degree of recurrent ptosis. (D) Preoperative
marks demonstrating a repeat circumvertical approach. (E) Final result showing appropriate lifting of the NAC and an overall esthetic shape.
A
B
C
D
E
postoperative visit and then routine incisional care is
started.
COMPLICATIONS AND
THEIR MANAGEMENT
All of the commonly recognized potential complications of
breast augmentation and mastopexy can occur when these
two procedures are combined. These include infection,
hematoma, seroma, hypertrophic scarring, delayed wound
healing, and capsular contracture. Treatment of these
complications mirrors what is commonly done for implant
or mastopexy patients in general. However, there are two
unique types of complications that tend to occur in MWL
augmentation/mastopexy patients: implant malposition and
recurrent ptosis.
Implant Malposition
Due to the loose nature of the skin envelope, postoperative
loss of the position of the IMF or even lateral implant dis­
placement can occur. In these cases, suture plication of the

148
PART | 3  Breast reshaping
6. Scopinaro N, Gianetta E, Pandolfo N, et al. Bilio-pancreatic bypass.
Proposal and preliminary experimental study of a new type of opera­
tion for the functional surgical treatment of obesity. Minerva Chir
1976;31(10):560–56.
7. Sebastian JL. Bariatric surgery and work-up of the massive weight
loss patient. Clin Plastic Surg 2008;35(1):11–26.
8. Song AY, Jean RD, Hurwitz DJ, et al. A classification of contour
deformities after bariatric weight loss: The Pittsburgh rating scale.
Plast Reconstr Surg 2005;116:1535.
9. Sarwer DB, Fabricatore AN. Psychiatric considerations of the
massive weight loss patient. Clin Plast Surg 2008;35:1–10.
10. Sarwer DB, Wadden TA, Fabricatore AN. Psychosocial and behav­
ioral aspects of bariatric surgery. Obes Res 2005;13(4):639–48.
11. Boccieri LE, Meana M, Fisher BL. A review of psychosocial out­
comes of surgery for morbid obesity. J Psychosom Res 2002;52(3):
155–65.
12. Herpetz S, Kielmann R, Wolf AM, et al. Does obesity surgery
improve psychosocial functioning? A systematic review. Int J Obes
Relat Metab Disord 2003;27(11):1300–14.
13. van Hout GC, van Oudheusden I, van Heck GL. Psychological
profile of the morbidly obese. Obes Surg 2002;14(5):479–88.
14. Losken A. Breast reshaping following massive weight loss: princi­
ples and techniques. Plast Reconstr Surg 2010;126(3):1075–85.
15. Rubin JP, Khaci G. Mastopexy after massive weight loss: dermal
suspension and selective auto-augmentation. Clin Plast Surg 2008;
35:123–9.
16. Rubin JP. Mastopexy in the massive weight loss patient: dermal
suspension and total parenchymal reshaping. Aesth Surg J 2006;
16:1622–9.
17. Gusenoff JA, Rubin JP. Plastic surgery after weight loss: current
concepts in massive weight loss surgery. Aesth Surg J 2008;28(4):
452–5.
18. Agha-Mohammadi S, Hurwitz DJ. Nutritional deficiency of post-
bariatric surgery body contouring patients: what every plastic
surgeon should know. Plast Reconstr Surg 2008;122:604–13.
19. Alvarez-Leite JI. Nutrient deficiencies secondary to bariatric surgery.
Curr Opin Clin Nutr Metab Care 2004;7:569–75.
20. Madan AK, Orth WS, Tichansky DS, et al. Vitamin and trace
mineral levels after laparoscopic gastric bypass. Obes Surg
2006;16:603–6.
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suture for control of areolar diameter and shape. Plast Reconstr Surg
2007;119:804.
22. Hammond DC, Hollender HA, Bouwense CL. The sit-up position in
breast surgery. Plast Reconstr Surg 2001;107(2):572–6.
23. Hammond DC, Alfonso D, Khuthaila DK. Mastopexy using the short
scar periareolar inferior pedicle reduction technique. Plast Reconstr
Surg 2008;121(5):1533–9.
24. Hammond DC. The short scar periareolar inferior pedicle reduction
(SPAIR) mammaplasty. Semin Plast Surg 2004;18(3):231–43.
25. Colen SR, Giese SY, Graf R, et al. Treatment of breast ptosis. Aesth
Surg J 2003;23(4):279–85.
26. Hammond DC. The SPAIR mammaplasty. Clin Plast Surg 2002;
29(3):411–21.
27. Hammond DC. Short scar periareolar inferior pedicle reduction
(SPAIR) mammaplasty. Plast Reconstr Surg 1999;103(3):890–901.
over dissected portion of the pocket can restore harmony
between the position of the implant and the overlying
breast. Such revisions are technically demanding but can
greatly improve the quality of the result esthetically.
Recurrent Ptosis
Even despite attempts to overcorrect the degree of tighten­
ing of the breast, particularly along the vertical component,
postoperative stretching of the skin with loss of an esthetic
lower pole contour can occur. Here, the advantage of the
combined procedure comes into play. Very often, simple
retightening of the vertical component will provide very
esthetic and permanent correction of this complication (Fig.
14.15A–E). When a staged procedure is performed, it can
be difficult to assess the degree of tightening needed to
create the desired shape. Therefore after the augmentation
is performed at the second procedure, postoperative stretch­
ing of the skin envelope can then necessitate a third proce­
dure to achieve the final desired result. A related complication
relates to widening or shape distortion of the areola despite
the use of the interlocking suture. Here, simple reapplica­
tion of the interlocking technique usually provides stable
and long-term correction of the problem.
CONCLUSION
Augmentation mastopexy is generally considered by
esthetic breast surgeons to be one of the most challenging
surgeries they perform. The level of complexity is com­
pounded when this already difficult procedure is performed
on the damaged, inelastic skin envelope that is seen in the
MWL patient. Despite these obstacles, with proper preop­
erative planning and the appropriate application of sound
surgical technique, excellent esthetic results can be obtained,
with a tremendous degree of patient satisfaction.
REFERENCES
1. Centers for Disease Control and Prevention, Department of Health and
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weight trends 1985-2009.
Accessed March 4, 2011.
2. Maggard MA, Shugarman LR, Suttorp M, et al. Meta-analysis: surgi­
cal treatment of obesity. Ann Intern Med 2005;142 (7):547–59.
3. Torres JC, Oca CF, Garrison RN. Gastric bypass: Roux-en-Y gastro­
jejunostomy from the lesser curvature. South Med J 1983;76(10):
1217–21.
4. Mason EE. Vertical banded gastroplasty for obesity. Ann Surg
1982;117(5):701–6.
5. Kuzmak LI. A review of seven years’ experience with silicone gastric
banding. Obes Surg 1991;1(4):403–8.

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© 2013 Elsevier Inc
Key Points
●
Liposuction of the upper back and bra rolls can
produce excellent outcomes, provided that attention is
paid to patient selection and surgical technique.
●
Positioning of the patient during surgery is important
in order to achieve the best outcome.
●
Wetting solution infiltration permits the procedure to
be accomplished with the least amount of blood loss
and minimizes surgeon fatigue.
●
In our experience, there are minimal complications
from performing liposuction to the upper back and bra
rolls.
●
Patients find satisfaction with their outcomes from this
treatment, once swelling is resolved.
Liposuction of upper back/bra rolls
Sebastião Nelson Edy Guerra, Renato Nelson de Moura Guerra, Ismael Santiago Vásquez,
Rodrigo Nelson de Moura Guerra and Antonio Luiz Rocha Gesualdi Fernandes Neto
INTRODUCTION
Liposuction of the upper back is very important in body
contouring surgery. Even considering that this region is
loose skin, allowing free movement of the torso and arms, it
shows good index of retraction after liposuction. We must
inform patients in advance about this feature of the skin, so
they do not feel that this is loose skin sagging caused by
liposuction. The skin resection is limited to people with
thinner skin and with excess skin hereditary characteristic.
Especially after the age of 46, when the first signs of skin
aging. Liposuction alone resolves the vast majority of cases.
ANATOMICAL ASPECTS
The back and its extension towards the breast is a region
of the body with its own characteristics in liposuction.
The thickness and the ratio between the lamellar and
areal layers in the thin individual oscillate from 0.3 to
0.5 cm for the lamellar layer and 1.0 to 1.2 cm for the
areolar layer, and may reach 0.5 to 0.8 cm for the lamellar
layers and 1.5 to 2.2 cm for the areolar layer in obese
individuals.
However, for morbid obesity these values may be
higher, highlighting the increase in the lamellar layer.
In liposuction the dense connective tissue is very impor­
tant because it is thicker in the upper back region, especially
in the grooves formed by the excess skin that can result from
both genetic inheritance (Fig. 15.1), obesity (Fig. 15.2A
and D), sagging senile (Fig. 15.3A, B) or post liposuction
(see Fig. 15.2 C and F).
Another important feature is the loose connective tissue
(Fig. 15.4B) that grips the skin and subcutaneous muscle
(aponeurosis) in this region making it easier to rip of the
whole skin and subcutaneous tissue without detaching it
surgically during resection flaps (Fig. 15.4C and D).
SURGICAL TREATMENT
Planning – Demarcation
Liposuction of the upper back can be performed only by
minimal incisions of 5 mm at each subsequent level of the
armpits (see Fig. 15.1A and C).
Where it is planned, resection of skin incisions may be
made in the flaps (see Fig. 15.4).
The upper line of resection of the back is marked by
pulling down the skin of this region and marking ± 2 cm
above the submammary horizontal extension of the line
(Fig. 15.5E and 15.8F).
The score line is bound low by the amount of skin which
is desirable to withdraw (see Fig. 15.5C and E).
It is important to clarify to the patient the possible fall
of the scar and the consequent need for additional correc­
tions that are usually made 3 months after liposuction.
Anesthesia
Even if the vast majority of surgeons prefer general anes­
thesia, infiltration with 500 ml of tumescent lipoplasty
wetting solution that contains epinephrine 1 : 1 000 000 to
hydrate tissues facilitates and reduces the bleeding incurred
by the use of the liposuction cannula.
Part 4  Upper trunk contouring
Chapter 15

150
PART | 4  Upper trunk contouring
FIG. 15.1  Constitutional skin flaccidity (genetics). The whole liposuction of the upper back was made through a minimal incision in the
posterior axilla (arrow). Pre- and postoperative views.
B
C
D
A

151
Chapter | 15  Liposuction of upper back/bra rolls
FIG. 15.2  Good skin retraction (A, B, D, E) shown. Thin and senile skin (C and F) may present residual skin protuberance.
A
B
C
D
E
F
Another option is to associate the thoracic epidural
anesthesia between T7/T8 and T10/T11 with a 0.9% saline
solution with a similar 1 ml of epinephrine solution and
30 ml of 2% lidocaine. This will give us a concentration of
0.133% lidocaine to provide anesthesia in the high points
not affected by the epidural.
A supplemental sedation provides comfort to the
patient.
Positioning on the Operation Table
Regardless of the surgeon’s preference for general anesthe­
sia or upper thoracic epidural complemented with axillary
local anesthesia, the position on the table may be in the
prone or lateral decubitus (see Fig. 15.4A). The latter allows
a better approach to the upper back, axillary contour, bra
rolls and abdomen.

152
PART | 4  Upper trunk contouring
FIG. 15.3  Resection of senile skin flaccidity.
A
B
FIG. 15.4  (A) Liposuction before skin resection. (B) Skin resection. (C) Excised skin. (D) Suture made (posterior view).
A
B
C
D

153
Chapter | 15  Liposuction of upper back/bra rolls
FIG. 15.5  Constitutional skin excess exacerbated by obesity (A–F). The sequence shows the demarcation of the back skin resection and associ­
ated mammaplasty.
A
B
C
D
E
F
Initially, our incisions, whenever possible, extend to the
end of the spine area, but we leave markings that allow us
to connect the incisions if necessary (see Figs 15.5F, 15.4D
and 15.5E).
When indicated, these incisions can be extended to the
anterior thorax with reverse resection of the upper abdomen
(reverse abdominoplasty) or surgical correction of the
breast (Figs 15.6 and 15.7).
POSTOPERATIVE CARE AND RESULTS
At the first examination, it is possible to assess with cer­
tainty the thickness of the skin, fat tissue to be aspirated,
sagging, and pre-existing skin excess.
The advantage of skin resection and its applicability is
questioned by the occasional widening of scars in patients
with thin skin and hypertrophy scars in patients with thicker
skin (see Figs 15.3B and 15.10), not excluding the fact
Surgical Technique
Liposuction is initiated from the deepest layer (lamellar)
(see Fig. 15.4A) to the most superficial layer (areolar). It
should be aspirated maximally from the lamellar layer,
because its larger and turgid cells are still softened by
wetting solution infiltration. It will result in a thicker layer
of fibrous connective tissue (see Fig. 15.4B), allowing a
better grip of this flap and lower recurrence of sagging. The
aspiration of the areolar layer is also significant, as it is
important for the surgeon to leave the thickness of the
tissues according to his preference.
In cases where the skin resection is programmed, lipo­
suction under the flap should be total. Thus, the resection
is reduced only to the skin layer, leaving the vascularization
and innervation intact. This avoids areas of paresthesia and
discomfort, which are sources of complaint from patients
(see Fig. 15.4B and C).

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PART | 4  Upper trunk contouring
FIG. 15.6  (A and B) Skin resection up to the lateral border of the breast (anterior view). (C and D) After suture, the surgical approach to the
breasts starts in dorsal decubitus.
A
B
C
D
that patients with thicker skin may also present scar
enlargement.
We limit physical fitness activities for 3 months. This
would not impair an early return to work.
The use of body shaping garments provides comfort
for the patient and helps stabilize the skin in its
position.
COMPLICATIONS
Some ecchymosis is common. Hematomas are rare, but
should be avoided, especially in liposuction accompanied
by skin resection.
Often liposuction of the back (see Fig. 15.1A and C) is
accompanied by liposuction of the hips and sacral region,
leaving these regions exposed to occasional fluid collec­
tions (seroma).
Treatment may require the application of a suction drain
for 3–4 days when the aspirated fluid collection volume is
above 40 ml.
The risk of skin necrosis is avoided by supporting the
operated area with a soft surface and evenly distributing the
weight over the entire surface of the patient (see Fig. 15.4A
and D).
Precise skin wound closures will prevent unsightly
scars.
CONCLUSION
Reviewing 902 cases of upper back liposuction, there were
23 cases (2.55%) of skin resection concurrent with liposuc­
tion of the back (see Fig. 15.2). This argues for very con­
servative practice, with skin resection reserved for cases of
severe pre-existing sagging (Fig. 15.8B–E and C–F), and
especially in patients undergoing major weight loss where
the skin has already suffered its maximum retraction.
Skin resection of the back has almost a formal indica­
tion in these cases and when properly indicated and per­
formed brings great benefits for the patient (Figs
15.9–15.11).

155
Chapter | 15  Liposuction of upper back/bra rolls
FIG. 15.7  The sequence shows the detachment (A), the nipple–areola complex delimitation (B), the skin resection (C and D) and the mounting
of the breast (E and F).
A
B
C
D
E
F
FIG. 15.8  Pre- and postoperative views (A and D, B and E, C and F). The whole skin flaccidity of the back was treated by the incision in the
back. The abdomen was treated with posterior surgical approach and the hips only with liposuction.
A
B
C
D
E
F

156
PART | 4  Upper trunk contouring
FIG. 15.9  The scar position is determined by the bra rolls (A and B). The dotted line (F) shows the final scar position.
A
B
C
D
E
F

157
Chapter | 15  Liposuction of upper back/bra rolls
FIG. 15.10  Pre- and postoperative views (A and D, B and E, C and F).
A
B
C
D
E
F

158
PART | 4  Upper trunk contouring
FIG. 15.11  Not rare, but patients use tattoos to hide scars, even if they are small.
A
B
C
D
E
F
When in doubt, perform liposuction and a subsequent
surgical resection (i.e., bra line lipectomy) after 3 months
or later.
FURTHER READING
Aly A, Cram A, Chao M, et al. Belt lipectomy for circumferential truncal
excess; the university of Iowa experience. Plast Reconstr Surg
2003;111:398–413.
Avelar JM, Illouz YG. Lipoaspiração. 1st ed. São Paulo: Hipócrates; 1986.
p. 45–57.
Baroudi R. Body contour surgery. Clin Plast Surg 1989;16(2):
263–77.
Baroudi R. Flankplasty:specific treatment to improve body contouring.
Ann Plast Surg 1991;27(5):404–20.
Illouz, YG. Study of subcutaneous fat. Aesth Plast Surg 1990;14(3):
165–77.
Illouz YG. Une nouvelle technique pour les lipodystrophies localisées.
Rev Chir Esth France 1980;6(9).
Markman B, Barton FE. Anatomy of the subcutaneous tissue of the trunk
and lower extremity. Plast Reconstr Surg 1987;80(2):248–54.
Rohrich RJ, Gosman AA, Conrad MH, et al. Simplifying circumferencial
body contouring: the central body lift evolution. Plast Recontr Surg
2006;118:525.
Souza Pinto EB. Lipoaspiração superficial. Rio de Janeiro: Revinter;
Chapter 3, 1999. p. 18–9.
Strauch B, Herman C, Rohde C, et al. Mid-body contouring in the post-
bariatric surgery patient. Plast Reconstr Surg 2006;117:2200.
Teimourian B, Gotkin R. Contouring of the midtrunk in overweight
patients. Aesth Plast Surg 1989;13:145–53.
Van Geertruyden JP, Vanderweyer E, de Fontaine S, et al. Circumferential
torsoplasty. Br J Plast Surg 1997;52:623–8.
Van Huizum MA, Roche NA, Hoper SOP. Circular belt lipectomy. A
retrospective follow-up study on perioperative complications and
cosmetic outcome. Ann Plast Surg 2005;54:459.

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© 2013 Elsevier Inc
Part 4  Upper trunk contouring
Key Points
●
Laxity of the upper back is not corrected by the
traditional lower body lift as the midline zone of
adherence prevents tension from being transmitted to
the upper back.
●
The entire back deformity including skin laxity, excess
adiposity and redundant lateral breast can be corrected
using the Bra Line Back Lift.
●
This technique is useful to contour the back in massive
weight loss patients or in individuals showing signs of
redundant skin and adiposity as a result of age.
●
The scar is well-tolerated by patients and easily
concealed beneath a bra or bathing suit top of the
patient’s own choosing.
●
The procedural learning curve is gentle for any plastic
surgeon with experience in excisional body
contouring.
Transverse upper body lift
Joseph P. Hunstad and Christopher D. Knotts
INTRODUCTION
A number of methods have been utilized to remove
and contour the excess tissue that can occur as a result of
normal aging or after fluctuations in weight. Many of these
techniques describe tissue removal along a dermatome
pattern;1–15 however, this tends to leave an oblique scar that
is difficult to conceal in normal clothing. Beginning in
2001, and first published in 2008, we developed a technique
of transverse upper back lifting, described as the Bra Line
Back Lift, to correct the deformity and place the final scar
where it is easily concealed beneath a bra or bathing suit
top.16 This procedure has been highly efficient in providing
complete correction of skin laxity and excess adiposity
in both the massive weight loss and normal weight
population.
Meticulous preoperative markings in the standing posi­
tion are essential to achieve a uniform and symmetrical
final outcome. These markings include realignment marks
that prevent tissue shifting and help ensure symmetry. A
three-layer closure places all tension at the level of the
superficial fascial system (SFS), minimizing tension on the
final skin closure and permitting a fine line scar. Our experi­
ence shows a low complication profile, consistent results,
and high patient satisfaction with this procedure.
PREOPERATIVE PREPARATION
We routinely check a complete blood count, comprehensive
metabolic panel, coagulation profile and Factor V Leiden
for all excisional body contouring patients. They are
instructed to discontinue aspirin and herbal medications for
two weeks prior to surgery.
Patient Evaluation
Patients with complaints of upper back tissue excess are
evaluated for skin quality, stretch marks, subcutaneous
adiposity and excess or hanging skin. Surgical judgement
and patient wishes are used to formulate a surgical plan.
Some patients are better candidates for standard tumescent
liposuction, adjunctive liposuction procedures using laser
or ultrasound, or direct excision in the form of a Bra Line
Back Lift. This chaper will focus on excisional lifting
(Fig. 16.1).
The patient is examined in a full-length mirror where
they can confirm the areas in need of correction. Redundant
tissue is firmly grasped and brought together using biman­
ual palpation to demonstrate to the patient what the final
outcome will be in terms of resected tissue. Because the
incision begins at the lateral inframammary fold, we also
manually gather excess tissue from the lateral breast area
to demonstrate the flank improvement which is often desir­
able to the patient. We ask patients to bring in their most
revealing bra or bathing suit top so we can discuss scar
placement and ensure their expectations will be met (Fig.
16.2). We also discuss the importance of keeping the arms
abducted until full tissue relaxation has occurred to make
sure the patient is comfortable with the post operative
requirements of the procedure. Full range of motion is
permitted by week six.
Chapter 16