Aesth Plast Surg (2010) 34:519–524 DOI 10.1007/s00266-010-9479-9

INNOVATIVE TECHNIQUES

Autologous Augmentation-Mastopexy After Bariatric Surgery: Waste Not Want Not! Daniel J. A. Thornton • Le Roux Fourie

Received: 30 July 2009 / Accepted: 11 February 2010 / Published online: 13 March 2010 Ó Springer Science+Business Media, LLC and International Society of Aesthetic Plastic Surgery 2010

Abstract Background The escalating trend in obesity is having major impact on health and the economy. As a result of NHS policies to reduce obesity, the number of patients losing weight following bariatric surgery is increasing rapidly. In addition to the systemic benefits to their general health, dramatic weight loss leads to marked changes in body habitus, with many patients seeking further ‘‘aesthetic’’ surgery to improve their appearance. We present our technique of autologous augmentation-mastopexy to address the problems of both skin excess and insufficient breast volume. Methods Our chosen method for mastopexy uses the Wisepattern skin excision. Augmentation of the breast deficient in volume is provided by a pedicled subcutaneous lateral thoracic perforator-based flap raised via a vertical continuation of the lateral mastopexy incision superiorly, often in continuity with a simultaneous brachioplasty incision. Results Thus far, six patients have undergone autologous augmentation mastopexy following massive weight loss (range = 36–79 kg, mean = 61 kg). Follow-up of these patients ranged from 1 to 18 months (mean = 12.5 months). Postoperative complications included a donor site seroma, haematoma, and scar contracture. All patients tolerated the procedure well and they felt that the improvement in breast and chest wall contour more than compensated for the donor site scar on the lateral chest wall.

D. J. A. Thornton
L. R. Fourie Pinderfields General Hospital, Aberford Road, WF1 4DG Wakefield, UK D. J. A. Thornton (&) 14 Beaumont Avenue, NG25 0BB Southwell, Notts, UK e-mail: [email protected]

Conclusion Autologous augmentation-mastopexy provides a robust augmentation, giving more natural ptotic breasts while avoiding the cost and potential complications of implant augmentation. The increased lateral flank scarring is well tolerated by these patients, with the additional benefit of reducing flank fullness. Keywords Bariatric surgery
Augmentation-mastopexy
Autologous breast augmentation

The exponential increase in the incidence of obesity in the UK is having major impact on both the health and economy of the nation. Medical consequences of obesity include malignant disease, musculoskeletal strain, cardiovascular disease, functional limitations of walking, intertrigo, and poor maintenance of adequate hygiene, bowel, and bladder habits. NHS policies to reduce obesity and its associated comorbidities are resulting in greater numbers of patients achieving massive weight loss (50–70% of their excess weight) with or without bariatric surgery. In addition to the systemic benefits to their general health, such dramatic weight loss leads to marked changes in their body habitus. Rapid loss of large volumes of subcutaneous fat results in a disproportionate excess of skin that most prominently affects the breasts, abdomen, lateral chest wall, medial arms, and thighs. As a result, many patients seek further ‘‘aesthetic’’ body contouring surgery to improve their body image [1], quality of life [1], and psychosocial integration. These patients usually require a multistage approach to address body-contouring issues in anatomically distinct areas of the body in order to achieve an optimal result. Large-volume skin excision necessitates long scars to achieve improvements in body contour and should be done only after weight loss has stabilised.

123

520

Following weight loss the breasts exhibit extreme ptosis due to reduction in volume and projection exacerbated by qualitative changes in the skin with loss of its natural elasticity. The aim of surgery is to achieve symmetry in size and shape of both the breast and the nipple-areola complex while addressing both the volume depletion and the marked ptosis. This requires a combination of breast augmentation and mastopexy rather than either method used alone. The technique of augmentation mastopexy evolved as a way to treat the ptotic hypoplastic breast [2, 3] but can be readily used following massive weight loss. The surgery is a complex procedure with increased likelihood of potential complications, including implant exposure, malposition, infection, nipple-areola loss, skin flap loss, increased scarring, and uncertainty over final nipple position. Traditionally, the augmentation component of the procedure has been carried out using implantable material, with the inherent risks of capsular contracture, leakage, rupture, rippling/folding, infection, mammographic shadowing, calcification of capsule, and malposition (especially in massive weight loss patients). More recently the trend has been to augment the breast with the patients own autologous tissue, thus avoiding implant-related complications and saving money while retaining a natural feel and appearance of the breast. It is particularly valuable in patients reluctant to consider implants due to unfounded health concerns. Autologous breast augmentation itself is not new. Free dermal fat grafts and fat injections lost credibility due to fat necrosis and cyst formation [4], although Coleman-style fat transfer is now making a resurgence in some hands. The classical breast reconstructive options of pedicled and free transverse rectus abdominis muscle (TRAM) flaps or

Fig. 1 a, b Preoperative skin markings

123

Aesth Plast Surg (2010) 34:519–524

latissimus dorsi (LD) flaps carry greater donor site morbidity than is deemed acceptable for an ‘‘aesthetic’’ augmentation. Free perforator flaps such as the deep inferior epigastric artery perforator (DIEP), the superior gluteal artery perforator (SGAP) and the lumbar artery perforator flaps spare muscle section but require technical expertise of microsurgical vascular anastomosis. The massive weight loss patient offers greater choice in local flap reconstruction due to a local excess of skin and subcutaneous tissue. Previously described local techniques post-bariatric surgery include the use of intercostal artery perforator flaps [5, 6], the spiral flap transposition of inframammary tissue performed in conjunction with a reverse abdominoplasty [7] and a transversely oriented lateral chest wall flap utilising the axillary skin roll [8].

Materials and Methods We describe a new technique of autologous augmentationmastopexy that utilises excess skin and subcutaneous tissue of the lateral chest wall as a vertically oriented pedicled transposition flap. The patient is marked preoperatively in the standing position. We favour the Wise-pattern skin excision [9] for the mastopexy element of the procedure following identification of the breast meridian, inframammary fold, and intended position of the lifted nipple-areola complex. Augmentation of the breast deficient in volume is provided by a vertically oriented, pedicled, subcutaneous, lateral thoracic perforator-based flap centred on the midaxillary line. This is raised via a superior continuation of the lateral mastopexy incisions, often in continuity with a simultaneous brachioplasty incision (Fig. 1a, b). Excess skin and

Aesth Plast Surg (2010) 34:519–524

subcutaneous tissue in the lateral chest wall is assessed by means of a pinch test to determine the available width of this donor flap. The patient is positioned supine on the operating table with both arms supported on arm boards, abducted to 90° and externally rotated. The excess skin of the breast is deepithelialised and the superior skin flaps, approximately 1.5 cm thick, are raised sufficiently far superiorly to accommodate both flap and breast pedicle while maintaining a smooth take-off on lateral profile. The nippleareola complex is mobilised down to the underlying pectoralis fascia on an inferiorly based pedicle. The vertically oriented skin paddle overlying the proposed flap is de-epithelialised. The superolateral margins of the flap are incised before the flap is raised from the tip superiorly to a broad base inferiorly, with care being taken to preserve any feeding lateral thoracic perforators visualised during the dissection (Fig. 2). Following massive weight loss this mobile flap easily tolerates transposition anteriorly beneath the superolateral skin flap and breast pedicle to augment both the superior pole and lateral margin of the breast (Fig. 3). After trimming the flap tip to healthy bleeding tissue, it is anchored to the underlying pectoralis fascia to prevent inferior migration and displacement. After haemostasis has been achieved, suction drains are placed to drain both breast and lateral chest donor site. The posterior skin margin of the donor defect in the lateral thoracic wall is advanced anteriorly and the flap donor site closed primarily. The nipple-areola complex is advanced superiorly to its desired position, superficial to the transposition flap. Skin closure of the Wise-pattern breast incisions proceeds using absorbable monofilament sutures for both deep dermal and subcuticular sutures (Fig. 4a, b).

521

Fig. 3 Flap transposition

If a brachioplasty is performed concurrently, the superior extent of the donor site scar is extended across the axilla posterior to the anterior axillary fold in continuity with the brachioplasty scar on the medial aspect of the arm.

Results Thus far, six patients have undergone autologous augmentation-mastopexy following massive weight loss (range = 36–79 kg, mean = 61 kg) using this technique, two of whom had a simultaneous brachioplasty. Follow-up of these patients ranged from 1 to 18 months. Postoperative complications included one donor site seroma requiring aspiration, one donor site haematoma requiring surgical evacuation, and one scar contracture of the lateral chest wall donor site, which improved with z-plasty scar revision. Stretching of the vertical donor site scar has been noted by the surgeon during subsequent follow-up but no patient has expressed dissatisfaction. All patients tolerated the procedure well and they felt that the improvement in breast and chest wall contour more than compensated for the donor site scar on the lateral chest wall. Figures 5 and 6 represent pre- and post-operative photographs of satisfied patients.

Discussion

Fig. 2 Flap perforator vessel

Alteration in body habitus following massive weight loss presents the plastic surgeon with a number of distinct anatomical sites requiring aesthetic consideration. In order to achieve an optimal result, patients undergoing bodycontouring surgery to the breast usually require additional surgical procedures to address skin and subcutaneous tissue

123

522

Aesth Plast Surg (2010) 34:519–524

Fig. 4 a, b Postoperative result

Fig. 5 a, b Preoperative views. c, d Six-week postoperative views. e, f 12-month postoperative view

excess in the lateral chest wall and upper arms to avoid aesthetic disharmony. Transposition of our flap reduces this lateral chest wall excess, and extension of the vertical donor site scar across the axilla can easily incorporate the brachioplasty excision. Performance of these procedures concurrently in patients who typically require multiple operations helps to further reduce the impact of surgical treatment, thus increasing patient satisfaction.

123

Volume depletion and ptosis of the breast demand augmentation-mastopexy. Local options involving repositioning of any excess mammary tissue have certain disadvantages; superior translocation of the autogenous gland requires significant central breast dissection risking NAC sensitivity, and techniques to roll up inferior breast tissue excess fall short of achieving superior pole fullness. We favour augmentation using redundant autologous tissue

Aesth Plast Surg (2010) 34:519–524

523

Fig. 6 a, b Preoperative views. c, d Six-week postoperative views. e, f 12-month postoperative views

from the lateral chest wall that would otherwise be discarded as a result of body-contouring surgery. This reduces the requirement for implants, which may be difficult to cover with a ptotic inelastic skin envelope, and removes the risks of complications and multiple procedures specific to implant augmentation. Our pedicled fasciocutaneous flap can be based on direct cutaneous perforators from the lateral thoracic or intercostal arteries, or on septocutaneous perforators from the thoracodorsal or long thoracic arteries. The vascularity of the flap is particularly robust in this population of patients as vessel hypertrophy achieved with weight gain is preserved following weight loss. The broad base to the flap may include more than one perforator and helps to prevent kinking of the vessels on transposition to the breast. Secure anchoring of the flap superiorly to the pectoralis fascia is essential to maintain superior pole fullness and to date we have not experienced any problems due to delayed pseudoptosis (‘bottoming out’) in the months following surgery. Perforator flaps in the flank were first described by Angrigiani et al. [10] and have been used to cover defects of the breast, thorax, abdomen, sacrum, or axilla. Various surgical techniques using pedicled intercostal artery perforator (ICAP) flaps have been described to augment the

breast following bariatric surgery [5, 6, 11]. In keeping with these techniques, our pedicled flap requires no microvascular anastomosis but has the advantage of straightforward pedicle dissection superficial to muscle without the need for islanding with its risk of kinking on rotation or transposition to the recipient site. In addition, patients prefer the improved contour of the lateral chest wall and less obvious vertical donor site scar compared with transverse scars extending onto the back [5–8, 11], enabling them to wear clothing that exposes their back with confidence. These factors reduce donor site morbidity, which is particularly important with respect to ‘‘aesthetic’’ surgical procedures.

Conclusions Autologous augmentation mastopexy using vertically oriented pedicled flaps from the lateral chest wall provides a robust augmentation with more natural-looking ptotic breasts while avoiding the cost and potential complications of implant augmentation. The donor site scarring is well tolerated by these patients who reap the additional benefit of a reduction of their flank excess. Accordingly, we

123

524

recommend this simple, reliable, transposition flap as a means of successfully augmenting the breast during augmentation-mastopexy following massive weight loss.

References 1. Song AY, Rubin JP, Thomas V, Dudas JR, Marra KG, Fernstrom MH (2006) Body image and quality of life in post massive weight loss body contouring patients. Obesity 14(9):1626–1636 2. Gonzales-Ulloa M (1960) Correction of hypotrophy of the breast by exogenous material. Plast Reconstr Surg 25:15–26 3. Regnault P (1966) The hypoplastic and ptotic breast: a combined operation with prosthetic augmentation. Plast Reconstr Surg 37:31–37 4. Beekman WH, Hage JJ, Jorna LB, Mulder JW (1999) Augmentation mammaplasty: the story before the silicone bag prosthesis. Ann Plast Surg 43:446–451

123

Aesth Plast Surg (2010) 34:519–524 5. Hamdi M, Van Landuyt K, De Frene B, Roche N, Blondeel P, Monstrey S (2006) The versatility of the inter-costal artery perforator (ICAP) flaps. J Plast Reconstr Aesthet Surg 59:644–652 6. Kwei S, Borud LJ, Lee BT (2006) Mastopexy with autologous augmentation after massive weight loss—the intercostal artery perforator (ICAP) flap. Ann Plast Surg 57(4):361–365 7. Hurwitz DJ, Agha-Mohammadi S (2006) Postbariatric surgery breast reshaping—the spiral flap. Ann Plast Surg 56(5):481–486 8. Rubin JP, O’Toole J, Agha-Mohammadi S (2007) Approach to the breast after weight loss. In: Rubin JP, Matarasso A (eds) Aesthetic surgery after massive weight loss. Saunders, Philadelphia, pp 37–48 9. Wise RJ (1956) A preliminary report on a method of planning the mammoplasty. Plast Reconstr Surg 17:367 10. Angrigiani C, Grilli D, Siebert J (1995) Latissimus dorsi musculocutaneous flap without muscle. Plast Reconstr Surg 96:1608– 1614 11. Van Landuyt K, Hamdi M, Blondeel P, Monstrey S (2004) Autologous breast augmentation by pedicled perforator flaps. Ann Plast Surg 53(4):322–327