The surgical solution often involves a skin reduction using the Wise pattern, in addition to augmentation to restore the loss of volume, or an implant along with breast reshaping with a mastopexy.
But these approaches can be limited because the skin may not hold up well with the implants.Alternative
As an alternative, Dennis J. Hurwitz, M.D., has developed the spiral flap, a complex de-epithelialized flap that, contiguous with the Wise pattern mastopexy, augments and reshapes the breast.
The technique offers the best results when combined with the upper body lift and an L-brachioplasty, a technique Dr. Hurwitz also developed to reshape the upper arm after massive weight loss.
"The spiral flap works to reposition the whole breast in the context of the upper body lift. It not only augments and enlarges, but it also helps to hold up and suspend the breast," explains Dr. Hurwitz, a clinical professor of plastic surgery at the University of Pittsburgh.
Specifically, the spiral flap involves taking some of the excess lateral flap of skin fat and, with the skin off of the breast, spinning it under the breast and over the pectoral muscle, like a spiral.
"The term 'spiral flap' refers to the geometric use of the flaps," Dr. Hurwitz says.
The next step — the upper body lift — is done in a manner that Dr. Hurwitz calls a "reverse abdominoplasty," in which the skin from the upper abdomen is moved upward toward the breast, and the incision is hidden in the intramammary fold. He combines that with the L-brachioplasty.
"(The L-brachioplasty) improves the armpit; so, altogether, you're not only making the breast right, but also the nearby structures of the chest and armpits."
The avoidance of implants can be desirable for patients, and since the surgery can take many hours, Dr. Hurwitz prefers not to introduce implants anyway.
"It's a long operation so I'd just a soon not introduce a foreign body with the potential for contamination," he says.
Dr. Hurwitz reports that he has so far conducted the spiral flap on 53 massive weight loss patients, with a follow-up from two to 26 months. Among 22 patients in a preliminary study, the procedure was described as the "definitive treatment" for 18 patients.
Four patients experienced fat necrosis, and in two the problem was resolved, however additional treatment was required for the other two.
Three of the patients were dissatisfied with their ultimate breast reshaping, due to complaints of poor back scars, breasts that were too small or had poor projection.
In addition to the potential risk for tip fat necrosis, other drawbacks of the procedure are the learning curve for surgeons, and the fact that the procedure is complicated and time consuming.
In general, however, Dr. Hurwitz says the payoff for the efforts are gratified patients.
"As a rule, there is a lot of patient satisfaction," he says.
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