Mastopexy after massive weight loss

Introduction

The US is seeing a rapid increase in obesity rate with a prevalence of 41.9%, which has increased from 30.5% in 1999–2000. Many people are able to lose weight and ameliorate their overall health through weight loss, diet, exercise and, sometimes, bariatric surgery. While weight loss is beneficial from a health perspective, many patients will also incur cosmetic sequalae caused by the reduction of large amounts of adipose tissue.

Massive weight loss is defined by a weight loss of more than 50 lb, and this in particular can cause severe disfigurement and body aesthetics. Breasts are severely impacted by these weight changes as illustrated by a loss of parenchymal volume and loss of skin elasticity leading to deflated, flattened, and ptotic breasts. In addition, the presence of lateral breast rolls that extend onto the chest wall disrupts the lateral curvature of the breast and frequently produces one continuous roll of soft tissue. This disease process provides a great challenge for the plastic surgeon who must take great care in the diagnosis and execution of the operative plan.

This chapter discusses the patient presentation and anatomic characteristics observed in the breast after massive weight loss. It also provides an overview of the preoperative assessment, surgical management and postoperative care required to achieve an aesthetically optimal result and minimize the risk of complications.

Diagnosis/patient presentation

Massive weight loss leads to a characteristic presentation of breast deformities that are very different from the traditional patients suffering from ptosis. The five common characteristics ( Fig. 6.1 ) found in these patients are:

• 1.

  Grade 3 ptosis

• 2.

  Asymmetric breast volume loss associated with breast deflation, breast flattening and loss of upper pole fullness

• 3.

  Nipple–areolar complex (NAC) medialization

• 4.

  Combination of skin elasticity loss and skin redundancy

• 5.

  Prominent skin and adipose roll extending from the lateral border of the breast into the chest wall. This blunts the aesthetic of the lateral breast, sometimes forming a single continuous roll of tissue.

A useful tool for the proper diagnosis and management of massive weight loss patient contour deformities is the validated “Pittsburgh Rating Scale”. This scale was designed to describe in detail the multitude of deformities after massive weight loss and recommend the optimal surgical option based on the severity of the contour deformity. This is especially helpful in the assessment of breast contour deformities where the commonly used breast ptosis scales (e.g. Regnault’s classification ) do not take into account the unique breast characteristics found in this group of patients. The Pittsburgh Rating Scale ranges from 0 to 3:

• 0 – normal breasts; these patients do not require operative treatment

• 1 – grade 1 and 2 ptosis, or severe macromastia; these patients may benefit from traditional mastopexy, reduction, or augmentation techniques

• 2 – grade III ptosis, or moderate volume loss, or constricted breast; these patients may benefit from traditional mastopexy with or without augmentation

• 3 – severe lateral breast/chest roll and/or severe volume depletion with redundant skin and flattened breast shape; these patients benefit from parenchymal reshaping techniques with dermal suspension, and autoaugmentation should be considered. These patients also develop NAC medialization, which is important to recognize to ensure the NAC is surgically lateralized along a true breast meridian.

Patient selection

Patient selection is crucial for optimal outcomes and the Pittsburgh Rating Scale can guide the plastic surgeon to offer the right operation to the right patient. Traditional mastopexy should be considered in patients with mild to moderated breast ptosis (Pittsburgh Rating Scale 1 and 2). However, dermal suspension and parenchymal reshaping with selective autoaugmentation is indicated in patients with more severe characteristics:

• Grade 3 ptosis

  • Loss of breast volume with breast flattening and loss of upper pole fullness

  • Inelastic and redundant skin

  • NAC medialization

  • Lateral breast/chest skin and adipose roll.

  The only absolute contraindication for the use of dermal suspension and parenchymal reshaping with selective autoaugmentation includes active use of tobacco products due to its vasoconstrictive action compromising the perfusion of the skin flaps. This technique relies heavily on extensive skin flap dissection and any risk factors compromising blood flow can place the patient in jeopardy. Relative contraindications for the use of dermal suspension and parenchymal reshaping with selective autoaugmentation include:

  • Prior breast scars. If located in areas where undermining is planned, the skin flaps perfusion can be compromised.

  • Insufficient breast parenchymal or lateral breast/chest roll volume. This would lead to an inadequate mobilization of the parenchyma and thus lead to a suboptimal breast mound.

  • Body mass index (BMI) greater than 35.

  • Diffuse fibrocystic disease or other breast pathology.

  • Active intertrigo.

Preoperative planning is especially crucial when dealing with massive weight loss patients. A detailed history should include current breast size and desired breast size, details about the prior bariatric surgery, BMI and nutritional status, current diet, smoking status, and personal or family history of venous thromboembolic event. Patients should aim to be at their goal weight (ideal BMI is under 30) and stable for at least the past 3 months. Bariatric patients usually achieve this weight stabilization around 12 and 18 months following bariatric surgery. Patient’s weight optimization is paramount; thus, in cases where the patient’s weight is higher than expected and they have not achieved their goal weight yet, they should return to their weight loss specialist for diet and exercise programs to help meet their goal weight. Action should be taken to ensure patients do not undergo surgery while being active tobacco users. These patients should be instructed to stop 1 month prior to and after surgery, and should be routinely tested with a cotinine urine test before surgery. A thorough physical examination of the breast should include inspection and palpations looking for scars, masses and lymphadenopathy. Surgeons should gauge skin quality, parenchymal volume, NAC position, and the size of a lateral breast/chest roll of skin and fat. This is important to determine if the patient has sufficient native breast parenchyma and lateral breast/chest roll to produce an adequately shaped and sized breast. Standard breast measurements should be taken especially sternal notch-to-nipple, nipple-to-inframammary fold (IMF) and breast width.

Patients should be cleared medically, and appropriate testing should be obtained prior to surgery. If needed, the procedure should be delayed in order to optimize the patient from a medical standpoint. Mammography is requested in accordance with the American Cancer Society guidelines. Patients should be asked to stop anticoagulation or antiplatelet therapy before surgery to minimize the risk of bleeding complications. Preoperative photographs should be taken from different angles. These are helpful for surgical planning as well as for comparison to postoperative results. Informed consent should be obtained discussing the procedure, alternative, risks and benefits. Patients should be made aware of what to expect on the day of surgery and discuss in detail the postoperative course. This is important to set patient’s expectations and address any concerns. The surgical plan, risks and benefits are reviewed again on the day of surgery to address any remaining concerns. Throughout the preoperative consultation, the plastic surgeon should gauge the patient’s aesthetic goals to ensure the expectations are realistic and can be met.