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Post-bariatric breast management rarely straightforward


Dr. Hurwitz
Chicago — Breast problems faced by patients who have undergone massive weight loss rarely lend themselves to easy solutions, says a leading cosmetic surgeon in this field.

With a growing number of patients undergoing bariatric surgery — and with these patients desiring more comprehensive improvements rather than focusing on obvious areas such as the abdomen and thighs — plastic surgeons are seeing growing numbers of patients presenting with breast management challenges related to massive weight loss, reports Dennis J. Hurwitz, M.D., F.A.C.S., clinical professor of surgery (plastic), University of Pittsburgh Medical Center, and director of the Hurwitz Center for Plastic Surgery.

Weight loss patients' requirements vary considerably, Dr. Hurwitz tells Cosmetic Surgery Times.

"But frankly, as a rule, they're not that simple. Most plastic surgeons realize that the nature of the problems they're dealing with don't lend themselves to simple breast augmentations or reductions because the breasts are very atrophic or flattened in appearance and sag considerably. And breast augmentation is not tolerated well by such patients, particularly the most atrophic," he says.

Another point to consider is that post-bariatric patients generally seek to avoid implants, Dr. Hurwitz explains.

He says, "They seem to have an aversion to typical cosmetic saline or silicone-filled breast implants. They don't want to add anything to their bodies because they've worked so hard to lose (weight)."

Post-bariatric patients like, wherever possible, to use their own tissue to fill out and shape their breasts, Dr. Hurwitz says.

"That should be done in concert with an upper body lift," he says. "This is important because the management of the breast in weight-loss patients should be done in the context of all the deformities that surround the breast. One shouldn't just do a breast reduction and come back later to take out a roll here or there. Plastic surgeons should become comfortable with evaluating and presenting the whole picture just as they would in craniofacial surgery," even if patients ultimately opt for simpler procedures.

Procedures

Dr. Hurwitz defines the upper body lift as a reverse abdominoplasty that adheres to the following principles (Hurwitz DJ. Ann Plast Surg. 2004 May;52(5):435-441; discussion 441.):

  • working backwards or upwards instead of downwards.
  • removing excess skin on the mid-torso across the epigastrium and the back roll creating a sturdy, better-positioned inframammary fold.

"If the patient desires a larger and better shaped breast," he adds, "I combine the upper body lift with what I call a spiral flap reconstruction. I call it that because of the rotation or turn upward that this flap takes. It's a combined flap of what would otherwise be discarded or unwanted tissue."

This flap is comprised of de-epithelialized skin and fat on the epigastrium that sits below the inframammary fold, he says. This tissue is recruited into the breast area, as is skin along the back, sometimes referred to as a thoracodorsal flap.

"That comes across from the breast, along the bra line, so that when one is finished, the residual scar will lie horizontally across the back under cover of the bra and the breast," Dr. Hurwitz says.

The epigastric flap flips upward like the lid of an envelope, he explains, providing bulk and shape to the undersurface of the de-epithelialized breast.

"To be able to do that, one must predict ahead of time how much skin one is going to remove from the upper abdomen in the reverse abdominoplasty," he says.

The thoracodorsal flap, on the other hand, flares straight back along the side of the breast, Dr. Hurwitz adds.


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