Upper Body Lift
The thoracic deformities that develop after massive weight loss are fairly complex.
Normally, the skin–fat envelope adheres tightly to the underlying musculoskeletal anatomy of the upper trunk.
The inframammary crease has a semicircular shape, with its lateral aspect rising superiorly as the lateral chest wall is approached .As we gain Weight thorax expand from the clavicle to the inframammary crease in both circumferential and vertical planes. After weight loss, the thorax deflates in the same way, resulting in two-dimensional excess—circumferential (horizontal) excess and vertical excess . but body has fascial attachments, called zones of adherence, located at the anterior and posterior midlines.
The anterior attachment is over the sternum and the posterior attachment is over the spine. During the process of weight gain, the zones of adherence prohibit fat deposition between the skin and the bony anatomy, acting to tether the overlying skin in place. As the patient loses weight, the zones of adherence act as suspension hooks for the hanging thoracic tissues leading to the final configuration of tissues .
Thoracic tissues located laterally tend to descend in massive weight loss patients because they are located at the greatest distance from either of the anterior and posterior zones of adherence. The degree to which any of these deformities occurs varies from patient to patient depending on their body mass index, their fat deposition/loss pattern, and the quality of their skin–fat envelope.
Our criteria for operating on patients with upper truncal deformities are similar to those for other regions of the body. The patient has to have stabilized his or her weight loss for at least 3 to 6 months. The key in deciding which procedure or procedures to perform in the upper truncal region is the position of the lateral inframammary crease. If it has ‘‘dropped out’’ or descended, then, by definition, the patient will have upper-back excess in varying degrees and, thus, an upper body lift, in one of its forms, is needed. we performe three forms of upper body lifts .
The male pattern is almost always accompanied by brachioplasty. The lateral thoracic component of the brachioplasty is extended inferiorly to allow for reduction of the horizontal excess that all of these patients present.
The upper body lift pattern used to treat females with lateral descent of the inframammary crease depends on the extent of upper-back excess.
The entire thoracic region of a massive weight loss patient is assessed as part of a total body examination. The thickness of the underlying fat is assessed in the anterior, lateral, and posterior regions of the chest. The location and the direction of the lateral inframammary crease in both women and men are assessed. As already mentioned, the key factor in determining whether an upper body lift is to be used in its entirety is the position of the lateral inframammary crease. If it is properly positioned, isolated procedures, such as brachioplasty and breast reshaping surgeries, can be performed. If the lateral crease position is lower than it should be, an upper body lift is appropriate. Next, the examiner notes the presence or absence of lateral breast rolls, which often continue posteriorly as upper-back rolls. In cases where the lateral inframammary crease is inferiorly displaced, lateral chest tissue should be pinched superiorly to determine the extent of the descent and the amount of improvement in the thoracic contour that could be attained after surgical correction. Continuation of this pinch posteriorly along the path of the upper-back roll also demonstrates the anticipated possible improvement of back contour. A vertical pinch of the posterior axillary fold, which is the extension of upper-arm excess, determines the extent of horizontal thoracic excess. A massive weight loss patient usually has many areas of complaint, including the thoracic region. The patient and surgeon need to outline all the areas to be addressed and formulate a plan and a schedule for treating different aspects of these deformities. A careful history of weight gain and weight loss should be taken to make sure of weight stability. It is important to make the patient an informed partner in the decision-making process by explaining the extent of deformities, how they The lamp shade analogy is helpful in demonstrating how the thoracic region presents in the massive weight loss patient. Like the lamp shade on the right, the thoracic soft tissue drapes toward the table and is held in place by the zones of adherence located in the anterior and posterior midlines
Details of the size and scar position are also discussed with the patient. For females, the desired breast size and shape are also discussed so that the appropriate technique to meet these goals is determined. It is often helpful to show photographs of previous surgical results to ensure that the patient has realistic expectations of what can be accomplished.
Operative technique Markings
The meticulous and precise marking based on the surgical plan is the cornerstone of a successful outcome. It is preferred to do the marking 1 day before surgery. This affords time to adequately photograph the markings, evaluate them, and adjust them before surgery, if needed. Because patients present with varying degrees of deformity, it is important to digest the principles underlying the marking process.
Male pattern After induction of general anesthesia, the patient is placed in the lateral decubitus position. An axillary roll is used and all pressure points are padded. The operating team of surgeons needs 360 access to operate on both the arm and upper back. This can be accomplished by turning the head of the table 180 from the anesthesiologist or by moving the table far enough away from the anesthesia equipment to allow access. The patient is then prepped and draped. The brachioplasty procedure is performed first. In male cases, the lateral chest wall component of the brachioplasty is closed with temporary staples to allow for adjustments during the breast component of the procedure. (In female cases, the Fig. 2. Marking for a male-type upper body lift. (From Aly AS. Upper body lift. In: Aly AS, editor. Body contouring after massive weight loss. St. Louis (MO): Quality Medical Publishing; 2005. p. 345; with permission.) Upper Body Lift 109 procedure is performed as described in the brachioplasty article by Aly and colleagues in this issue.) After the brachioplasty component is accomplished, the proposed superior extent of the lateral breast and upper-back rolls is incised down to the level of the underlying muscle fascia. An inferiorly based skin–fat flap is elevated down to the proposed inferior level of resection. Next, with the flap elevated superiorly while the shoulder is pushed inferiorly, the flap is tailored to the superior line of excision. Closure is accomplished in two layers with an overlying layer of skin glue. A closed suction is placed in the area of resection. At this point of the procedure, upper-arm excess is eliminated, the lateral breast and upper-back rolls are eliminated, the lateral inframammary crease is Fig. 3. Patient before (left) and after (right) a male-pattern upper body lift. 110 Soliman et al elevated to its proper position, and a ‘‘dog ear’’ is created at the lateral inferior pole of the breast, especially in male patients. After both sides are completed, the patient is placed in the supine position to perform the planned breast reconstruction. In men, a gynecomastia procedure is planned.
For women, the plan varies according to the deformity and the patient’s desires. In the gynecomastia procedure, the inframammary crease, in its elevated proper lateral position, is incised and the dissection is taken down to the level of the underlying muscle fascia. This maneuver usually results in the crease falling down and away from its original position because of gravity and lack of good adherence of the inframammary crease in the massive weight loss patient. To reconstruct the crease in its superior position, it is sutured with large permanent sutures to the underlying rib perichondrium at the appropriate level along the entire length of the crease. In some patients, this is fairly close to the inferior border of the pectoralis muscle. In others, it is slightly lower. Superiorly the breast tissue is elevated at the level of the pectoralis fascia up to the second rib. The nipple–areolar complex is harvested as a full thickness graft with an approximate diameter of 2.5 cm in males. The temporary staples from the lateral chest wall closure of the brachioplasty are removed and the breast flap is advanced inferiorly and laterally in a ‘‘vest over pants’’ manner. The excess is tailored inferiorly and laterally. A closed suction drain is placed in the breast pocket through separate incisions, and the wound is closed in layers. After checking both breasts for symmetry, the new positions for the nipple–areola complexes are marked. The authors feel that the best position for the nipple–areolar complex in a male is just lateral to the meridian and slightly above the inframammary crease. A 2.5-cm circular area is de-epithelized where the nipple–areolar complex is to be placed and the full thickness graft is appliedshows a patient before and 1 year after an upper body lift. Note the elimination of the anterior and posterior inverted ‘‘V’’ deformities; elevation of the entire inframammary crease, especially its lateral component; and the elimination of the upper-back roll. By leaving some excess fat on the tailored breast flap, it is possible to give the impression that the patient has some fullness to his pectoralis muscle, which can be aesthetically pleasing.
Female pattern type I and type II In most female massive weight loss patients that have a ‘‘dropped out’’ lateral inframammary crease, an upper body lift is required to eliminate upper back excess. The upper-back excess can present in a variety of forms anywhere from extensive upperback rolls to mild excess. The upper body lift also lifts the lateral inframammary crease to its appropriate position to create an appropriate base upon which the breast can be reconstructed. In the male-patient pattern described above, the lateral thoracic excision of the brachioplasty component of an upper body lift is very aggressive to eliminate the horizontal thoracic excess. In females, horizontal excess does not necessarily need to be eliminated because the accompanying breast reconstruction usually requires some horizontal excess to accommodate the increased projection. Thus, in many patients, the pattern of excision from the brachioplasty component does not connect with the excision of the upper-back and lateral breast rolls
We call this female pattern type I and it is the most common pattern used in females in our practice. Ideal patients for this procedure have a large amount of upper-back excess, which requires a bra-line excision to create the appropriate contour. Another important consideration in the female patient is that in creating the lines of excision, the lateral border of the breast has to be respected. Thus, it must be left intact. As in the male pattern of upper body lifting, the inframammary crease usually requires reinforcement by attaching it to its proper position with deep permanent utures that go through the underlying rib perichondrium.
Females who present with a minimal amount of upper-back excess that only manifests itself as loose tissue apparent above a worn bra are good candidates for female pattern type II upper body lifts. This pattern eliminates the excess through a continuation of the brachioplasty excision down through the lateral chest to the inframammary crease . Because the upper-back excess is minimal, the excisional pattern allows for the upward rotation of upper-back tissue along the entire length of the excision. This, as with all upper body lift techniques, elevates the lateral inframammary crease to its proper position (Fig. 7). With this pattern of excision, the surgeon must be careful not to lateralize the breast. Thus, to prevent breast lateralization, it may be warranted to perform the breast procedure first when using this pattern so that the resection can be adjusted.
Complications Outside of complications of bleeding, infection, and potential unattractive scarring, which are common to all surgical procedures, the most common complications of upper body lifts are wound separation and/or dehiscence, usually occurring near the lateral aspect of the breast.