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Islanded pedicled superior epigastric artery perforator flaps for bilateral breast augmentation with mastopexy after massive weight loss
Journal of Plastic, Reconstructive & Aesthetic Surgery (2011) 64, 1677e1681
CASE REPORT
Islanded pedicled superior epigastric artery perforator flaps for bilateral breast augmentation with mastopexy after massive weight loss* P. Szychta, W.D. Anderson* Department of Plastic and Reconstructive Surgery, St John’s Hospital, Howden Road West, Livingston, West Lothian EH54 6PP, UK Received 12 April 2011; accepted 22 April 2011
KEYWORDS SEA; Islanded pedicled superior epigastric artery perforator flap; Mastopexy; Breast surgery; Massive weight loss; Autologous breast augmentation; Augmentation mastopexy
Summary Objective: To present a surgical technique of recruiting tissue from the abdominal wall, based on the superior epigastric artery perforators, in order to provide autologous augmentation of the breasts with mastopexy in patients after massive weight loss. Case report: A 39-year-old woman presented to the plastic surgery outpatient clinic with significant bilateral breast deformity following massive weight loss of 85.5 kg. She was dissatisfied with the appearance of her breasts and abdomen despite previous Fleur-de-lis abdominoplasty. On examination, the patient had major ptosis with a deflated breast skin envelope and near-total absence of breast volume. She had insignificant brachial skin excess and limited excess of the lateral chest wall. There was a large element of residual skin redundancy in her upper abdomen. Surgical technique: Bilaterally, islanded superior epigastric artery perforator flaps were harvested from the epigastric region. In addition, turnover flaps were raised from the lateral chest wall. Inferior pedicled mastopexy was performed and the flaps were secured to the anterior chest wall in order to augment the breasts. Conclusions: The islanded pedicled superior epigastric artery perforator flap is a useful technique for utilising the upper epigastric abdominal excess to augment the breasts following previous massive weight loss, obviating the need for implants and therefore eliminating potential implant-related complications. ª 2011 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.
* Presented during: The Royal Society of Medicine Meeting, Edinburgh/London, Great Britain, 8 March 2011; 1st Prize Award of the Royal Society of Medicine. * Corresponding author. Tel.: þ44 7905338884. E-mail addresses: [email protected] (P. Szychta), [email protected] (W.D. Anderson).
1748-6815/$ - see front matter ª 2011 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.bjps.2011.04.025
1678 Recent dramatic increase in patients presenting after massive weight loss has led to a new subspeciality in plastic surgery for reshaping of the body silhouette. This field is increasingly recognised as a vital component to the multidisciplinary treatment approach to care for these patients.1 The breast, especially in the female, displays a variety of deformations after massive weight loss and reshaping of the breasts is of high importance to these patients.1 Most commonly, the patients request a more youthful, lifted appearance of their breasts with restoration of volume. Innovative techniques to address this have been offered in the literature, such as the spiral flap,2 total parenchymal reshaping,3,4 and pedicled perforator flaps.6,8 This article aims to present an innovative surgical technique of recruiting tissue from the abdominal wall based on the superior epigastric artery perforators to provide autologous volume replacement for the breasts.5,7,9e11 This can take advantage of excess tissue that otherwise would be discarded.
P. Szychta, W.D. Anderson following massive weight loss (85.5 kg) over a period of 3 years through diet and exercise alone. She has previously undergone Fleur-de-lis abdominoplasty in another hospital and was dissatisfied with the appearance of her breasts and abdomen.12 On examination, there was a deflated breast skin envelope with near-total absence of breast volume. There was major ptosis and no palpable masses. She had good pectoral muscle development. There was a minor degree of brachial skin excess and redundancy of the lateral chest wall skin. There was substantial residual skin redundancy in her upper abdomen despite previous Fleur-de-lis abdominoplasty (Figure 1). Preoperatively, a hand-held Doppler ultrasound of the abdominal wall identified a number of perforators on each side. The patient underwent bilateral inferior pedicled mastopexy and bilateral autologous breast augmentation with superior epigastric artery perforator flaps (Figure 2).
Surgical technique Case report A 39-year-old woman was seen in the plastic surgery outpatient clinic for significant bilateral breast deformity
On each side, flaps were marked to include the upper abdominal skin excess and perforators were marked with the help of a hand-held Doppler. The flap was dissected to
Figure 1 Preoperative view of the patient; visible ptotic breasts and redundant skin of the abdominal wall with no significantly excessive tissues on the lateral chest wall.
Autologous breast augmentation technique the rectus sheath and several perforators were identified. A more distal perforator was selected on both sides to increase pedicle length and the remaining perforators were micro-clamped to ensure skin perfusion was satisfactory. Subsequently, the perforator was dissected through the sheath and the rectus muscle to the costal margin and medial suprafascial tunnels were created for flap transfer to the breasts. Bilateral inferior pedicled mastopexy was performed and deepithalised lateral turnover flaps were harvested from the lateral chest wall and brought across the inferior pole of the breast and secured to the chest wall. The abdominal flaps were placed in the superomedial portion of the breast and the mastopexy closure was performed with 3/0 and 4/0 monocryl with a single suction drain on each side. Postoperatively, observation for excess drainage or haematoma was undertaken. The drains were removed on
1679 day 4. Pressure was avoided over the medial costal margin where the pedicle was situated for 3 weeks after the surgery. Deep venous thrombosis (DVT) prophylaxsis was administered. The patient was delighted with the result of the surgery (Figure 3). There was, however, a small sinus at the 12 o’clock position of the left nipple-areolar complex, which is being managed conservatively. A small excess of skin in the xiphisternal region remains and it will be revised in due course.
Discussion Patients with breast ptosis subsequent to massive weight loss, who are subjected to mastopexy and augmentation with implants, experience a high incidence of complications. In
Figure 2 Surgical technique of the islanded pedicled superior epigastric artery perforator flap for autologous breast augmentation. a. flap dissected to the rectus muscle sheath. b, c. perforator dissected through rectus sheath and muscle. d. costal margin suprafascial medial tunnel for the flap created. e. flap deepithalized, passed through the tunnel and placed medially.
1680 addition, in some cases, precise implant positioning to produce an aesthetically pleasing long-term result can be very challenging because of the skin excess of the ptotic breast as well as the unsatisfactory volume of covering tissues.13 Thus, breast reshaping with mastopexy and augmentation with autologous tissues have significant advantages in terms of both, results and complications. Pedicled superior epigastric artery perforator (SEAP) flaps have been used for trunk and extremity reconstruction.5e11,14 However, we found no report concerning breast augmentation with SEAP flaps. There are several advantages of the described surgical technique, including the use of excess tissue that otherwise would be discarded. It demonstrates potential to recruit residual redundant tissue from the upper abdomen as a perforator flap on each side for autologous volume replacement providing optimal breast shape and consistency, no need for breast prosthesis with potential high risk of complications, lack of additional scarring in lateral thoracic region and simultaneous complex aesthetic correction of breast and abdomen. The drawback of the procedure is its duration, which in our case was 6 h. However, we anticipate reducing the duration of surgery with increased experience. There is also risk of inadequate pedicle length, unless a more distal perforator is selected. We suggest that patients with excessive, loose skin of the abdomen after massive weight loss, who would benefit
P. Szychta, W.D. Anderson from a Fleur-de-lis abdominoplasty and require breast reshaping for ptotic breasts with insufficient volume, can benefit from combining mastopexy with autologous breast augmentation using islanded pedicled SEAP flaps. Recently, the complex procedure of mastopexy and abdominoplasty has been reported but the tissues from abdominal wall were not used to help in reshaping the breast.15 Spiral flaps and other lateral thoracic perforatorbased flaps have also been described in the literature and can be reliable methods in the case of patients with ptotic breasts and excessive skin of the lateral thoracic region.2,16,17 Fleur-de-lis abdominoplasty is usually indicated in this patient population and the flap for the breast augmentation can be harvested from the epigastric region when there is inadequate skin on the lateral chest wall. Harvesting flaps from the lateral chest wall involves additional scarring but benefits reduction of skin excess at this site and can, as in this case, be combined with SEAP flaps. Dermal suspension and total parenchymal reshaping is a promising technique in selected patients with sufficient breast volume and relatively low positioned nipple-areola complex.3 However, some patients have long, ptotic breasts with the need of mastopexy and breast augmentation because the overall volume is inadequate. In conclusion, the islanded pedicled SEAP flap is a useful technique for utilising the upper epigastric abdominal excess to augment both breasts following previous massive weight loss. In addition, it obviates the need for implants
Figure 3 Postoperative view of the patient 3 months after bilateral mastopexy and autologous breast augmentation with islanded pedicled superior epigastric artery perforator flaps.
Autologous breast augmentation technique and therefore eliminates the potential high risk of implantrelated complications.
Ethical approval None.
Funding None.
Conflicts of interest None declared.
References 1. Huemer GM. Upper body reshaping for the woman with massive weight loss: An algorithmic approach. Aesth Plast Surg 2010; 34:561e9. 2. Hurwitz DJ, Agha-Mohammadi S. Postbariatric surgery breast reshaping: the spiral flap. Ann Plast Surg 2006;56:481e6. 3. Rubin JP, Khachi G. Mastopexy after massive weight loss: dermal suspension and selective auto-augmentation. Clin Plast Surg 2008;35:123e9. 4. Rubin JP. Mastopexy after massive weight loss: Dermal suspension and total parenchymal reshaping. Aesthetic Surg J 2006;26:214e22. 5. Hamdi M, Landuyt K, Ulens S, et al. Clinical applications of the superior epigastric artery perforator (SEAP) flap: anatomical studies and preoperative perforator mapping with multidetector CT. J Plast Reconstr Aesthet Surg 2009;62:1127e34.
1681 6. Hamdi M, Van Landuyt K, Hijjawi JB, et al. Surgical technique in pedicled thoracodorsal artery perforator flaps: a clinical experience with 99 patients. Plast Reconstr Surg 2008;121: 1632e41. 7. Woo KJ, Pyon JK, Lim SY, et al. Deep superior epigastric artery perforator ‘propeller’ flap for abdominal wall reconstruction: A case report. J Plast Reconstr Surg 2010;63:1223e6. 8. Hyakusoku H, Yamamoto T, Fumiiri M. The propeller flap method. Br J Plast Surg 1991;44:53e4. 9. Uemura T. Superior epigastric artery perforator flap: preliminary report. Plast Reconstr Surg 2007;120:1ee5e. 10. Mah E, Rozen WM, Ashton MW. Deep superior epigastric artery perforators: anatomical study and clinical application in sternal reconstruction. Plast Reconstr Surg 2009;123:1719e23. 11. Deiler S, Zulkowski R, Muensterer O, et al. Pedicled superior epigastric perforator flap for reconstruction of a soft tissue defect at the ventral thoracic wall. Eur J Plast Surg 2007;30: 141e6. 12. Duff CG, Aslam S, Griffiths RW. Fleur-de-Lys abdominoplastyda consecutive case series. BAPS 2003;56:557e66. 13. Migliori FC, Gabrielli A, Rizzo R, et al. Breast contouring in postbariatric patients: a technique selection algorithm. Obes Surg 2010;20:651e6. 14. Boyd JB, Taylor GI, Corlett R. The vascular territories of the superior epigastric and the deep inferior epigastric systems. Plast Reconstr Surg 1984;73:1e16. 15. Rhomberg M, Pu ¨lzl P, Piza-Katzer H. Single-stage abdominoplasty and mastopexy after weight loss following gastric banding. Obes Surg 2010;13:418e23. 16. Hamdi M, Van Landuyt K, Blondeel P, et al. Autologous breast augmentation with the lateral intercostal artery perforator flap in massive weight loss patients. J Plast Reconstr Aesthet Surg 2009;62:65e70. 17. Graf RM, Mansur AEC, Tenius FP, et al. Mastopexy after massive weight loss: Extended chest wallebased flap associated with a loop of pectoralis muscle. Aesth Plast Surg 2008;32:371e4.
CASE REPORT
Islanded pedicled superior epigastric artery perforator flaps for bilateral breast augmentation with mastopexy after massive weight loss* P. Szychta, W.D. Anderson* Department of Plastic and Reconstructive Surgery, St John’s Hospital, Howden Road West, Livingston, West Lothian EH54 6PP, UK Received 12 April 2011; accepted 22 April 2011
KEYWORDS SEA; Islanded pedicled superior epigastric artery perforator flap; Mastopexy; Breast surgery; Massive weight loss; Autologous breast augmentation; Augmentation mastopexy
Summary Objective: To present a surgical technique of recruiting tissue from the abdominal wall, based on the superior epigastric artery perforators, in order to provide autologous augmentation of the breasts with mastopexy in patients after massive weight loss. Case report: A 39-year-old woman presented to the plastic surgery outpatient clinic with significant bilateral breast deformity following massive weight loss of 85.5 kg. She was dissatisfied with the appearance of her breasts and abdomen despite previous Fleur-de-lis abdominoplasty. On examination, the patient had major ptosis with a deflated breast skin envelope and near-total absence of breast volume. She had insignificant brachial skin excess and limited excess of the lateral chest wall. There was a large element of residual skin redundancy in her upper abdomen. Surgical technique: Bilaterally, islanded superior epigastric artery perforator flaps were harvested from the epigastric region. In addition, turnover flaps were raised from the lateral chest wall. Inferior pedicled mastopexy was performed and the flaps were secured to the anterior chest wall in order to augment the breasts. Conclusions: The islanded pedicled superior epigastric artery perforator flap is a useful technique for utilising the upper epigastric abdominal excess to augment the breasts following previous massive weight loss, obviating the need for implants and therefore eliminating potential implant-related complications. ª 2011 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.
* Presented during: The Royal Society of Medicine Meeting, Edinburgh/London, Great Britain, 8 March 2011; 1st Prize Award of the Royal Society of Medicine. * Corresponding author. Tel.: þ44 7905338884. E-mail addresses: [email protected] (P. Szychta), [email protected] (W.D. Anderson).
1748-6815/$ - see front matter ª 2011 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.bjps.2011.04.025
1678 Recent dramatic increase in patients presenting after massive weight loss has led to a new subspeciality in plastic surgery for reshaping of the body silhouette. This field is increasingly recognised as a vital component to the multidisciplinary treatment approach to care for these patients.1 The breast, especially in the female, displays a variety of deformations after massive weight loss and reshaping of the breasts is of high importance to these patients.1 Most commonly, the patients request a more youthful, lifted appearance of their breasts with restoration of volume. Innovative techniques to address this have been offered in the literature, such as the spiral flap,2 total parenchymal reshaping,3,4 and pedicled perforator flaps.6,8 This article aims to present an innovative surgical technique of recruiting tissue from the abdominal wall based on the superior epigastric artery perforators to provide autologous volume replacement for the breasts.5,7,9e11 This can take advantage of excess tissue that otherwise would be discarded.
P. Szychta, W.D. Anderson following massive weight loss (85.5 kg) over a period of 3 years through diet and exercise alone. She has previously undergone Fleur-de-lis abdominoplasty in another hospital and was dissatisfied with the appearance of her breasts and abdomen.12 On examination, there was a deflated breast skin envelope with near-total absence of breast volume. There was major ptosis and no palpable masses. She had good pectoral muscle development. There was a minor degree of brachial skin excess and redundancy of the lateral chest wall skin. There was substantial residual skin redundancy in her upper abdomen despite previous Fleur-de-lis abdominoplasty (Figure 1). Preoperatively, a hand-held Doppler ultrasound of the abdominal wall identified a number of perforators on each side. The patient underwent bilateral inferior pedicled mastopexy and bilateral autologous breast augmentation with superior epigastric artery perforator flaps (Figure 2).
Surgical technique Case report A 39-year-old woman was seen in the plastic surgery outpatient clinic for significant bilateral breast deformity
On each side, flaps were marked to include the upper abdominal skin excess and perforators were marked with the help of a hand-held Doppler. The flap was dissected to
Figure 1 Preoperative view of the patient; visible ptotic breasts and redundant skin of the abdominal wall with no significantly excessive tissues on the lateral chest wall.
Autologous breast augmentation technique the rectus sheath and several perforators were identified. A more distal perforator was selected on both sides to increase pedicle length and the remaining perforators were micro-clamped to ensure skin perfusion was satisfactory. Subsequently, the perforator was dissected through the sheath and the rectus muscle to the costal margin and medial suprafascial tunnels were created for flap transfer to the breasts. Bilateral inferior pedicled mastopexy was performed and deepithalised lateral turnover flaps were harvested from the lateral chest wall and brought across the inferior pole of the breast and secured to the chest wall. The abdominal flaps were placed in the superomedial portion of the breast and the mastopexy closure was performed with 3/0 and 4/0 monocryl with a single suction drain on each side. Postoperatively, observation for excess drainage or haematoma was undertaken. The drains were removed on
1679 day 4. Pressure was avoided over the medial costal margin where the pedicle was situated for 3 weeks after the surgery. Deep venous thrombosis (DVT) prophylaxsis was administered. The patient was delighted with the result of the surgery (Figure 3). There was, however, a small sinus at the 12 o’clock position of the left nipple-areolar complex, which is being managed conservatively. A small excess of skin in the xiphisternal region remains and it will be revised in due course.
Discussion Patients with breast ptosis subsequent to massive weight loss, who are subjected to mastopexy and augmentation with implants, experience a high incidence of complications. In
Figure 2 Surgical technique of the islanded pedicled superior epigastric artery perforator flap for autologous breast augmentation. a. flap dissected to the rectus muscle sheath. b, c. perforator dissected through rectus sheath and muscle. d. costal margin suprafascial medial tunnel for the flap created. e. flap deepithalized, passed through the tunnel and placed medially.
1680 addition, in some cases, precise implant positioning to produce an aesthetically pleasing long-term result can be very challenging because of the skin excess of the ptotic breast as well as the unsatisfactory volume of covering tissues.13 Thus, breast reshaping with mastopexy and augmentation with autologous tissues have significant advantages in terms of both, results and complications. Pedicled superior epigastric artery perforator (SEAP) flaps have been used for trunk and extremity reconstruction.5e11,14 However, we found no report concerning breast augmentation with SEAP flaps. There are several advantages of the described surgical technique, including the use of excess tissue that otherwise would be discarded. It demonstrates potential to recruit residual redundant tissue from the upper abdomen as a perforator flap on each side for autologous volume replacement providing optimal breast shape and consistency, no need for breast prosthesis with potential high risk of complications, lack of additional scarring in lateral thoracic region and simultaneous complex aesthetic correction of breast and abdomen. The drawback of the procedure is its duration, which in our case was 6 h. However, we anticipate reducing the duration of surgery with increased experience. There is also risk of inadequate pedicle length, unless a more distal perforator is selected. We suggest that patients with excessive, loose skin of the abdomen after massive weight loss, who would benefit
P. Szychta, W.D. Anderson from a Fleur-de-lis abdominoplasty and require breast reshaping for ptotic breasts with insufficient volume, can benefit from combining mastopexy with autologous breast augmentation using islanded pedicled SEAP flaps. Recently, the complex procedure of mastopexy and abdominoplasty has been reported but the tissues from abdominal wall were not used to help in reshaping the breast.15 Spiral flaps and other lateral thoracic perforatorbased flaps have also been described in the literature and can be reliable methods in the case of patients with ptotic breasts and excessive skin of the lateral thoracic region.2,16,17 Fleur-de-lis abdominoplasty is usually indicated in this patient population and the flap for the breast augmentation can be harvested from the epigastric region when there is inadequate skin on the lateral chest wall. Harvesting flaps from the lateral chest wall involves additional scarring but benefits reduction of skin excess at this site and can, as in this case, be combined with SEAP flaps. Dermal suspension and total parenchymal reshaping is a promising technique in selected patients with sufficient breast volume and relatively low positioned nipple-areola complex.3 However, some patients have long, ptotic breasts with the need of mastopexy and breast augmentation because the overall volume is inadequate. In conclusion, the islanded pedicled SEAP flap is a useful technique for utilising the upper epigastric abdominal excess to augment both breasts following previous massive weight loss. In addition, it obviates the need for implants
Figure 3 Postoperative view of the patient 3 months after bilateral mastopexy and autologous breast augmentation with islanded pedicled superior epigastric artery perforator flaps.
Autologous breast augmentation technique and therefore eliminates the potential high risk of implantrelated complications.
Ethical approval None.
Funding None.
Conflicts of interest None declared.
References 1. Huemer GM. Upper body reshaping for the woman with massive weight loss: An algorithmic approach. Aesth Plast Surg 2010; 34:561e9. 2. Hurwitz DJ, Agha-Mohammadi S. Postbariatric surgery breast reshaping: the spiral flap. Ann Plast Surg 2006;56:481e6. 3. Rubin JP, Khachi G. Mastopexy after massive weight loss: dermal suspension and selective auto-augmentation. Clin Plast Surg 2008;35:123e9. 4. Rubin JP. Mastopexy after massive weight loss: Dermal suspension and total parenchymal reshaping. Aesthetic Surg J 2006;26:214e22. 5. Hamdi M, Landuyt K, Ulens S, et al. Clinical applications of the superior epigastric artery perforator (SEAP) flap: anatomical studies and preoperative perforator mapping with multidetector CT. J Plast Reconstr Aesthet Surg 2009;62:1127e34.
1681 6. Hamdi M, Van Landuyt K, Hijjawi JB, et al. Surgical technique in pedicled thoracodorsal artery perforator flaps: a clinical experience with 99 patients. Plast Reconstr Surg 2008;121: 1632e41. 7. Woo KJ, Pyon JK, Lim SY, et al. Deep superior epigastric artery perforator ‘propeller’ flap for abdominal wall reconstruction: A case report. J Plast Reconstr Surg 2010;63:1223e6. 8. Hyakusoku H, Yamamoto T, Fumiiri M. The propeller flap method. Br J Plast Surg 1991;44:53e4. 9. Uemura T. Superior epigastric artery perforator flap: preliminary report. Plast Reconstr Surg 2007;120:1ee5e. 10. Mah E, Rozen WM, Ashton MW. Deep superior epigastric artery perforators: anatomical study and clinical application in sternal reconstruction. Plast Reconstr Surg 2009;123:1719e23. 11. Deiler S, Zulkowski R, Muensterer O, et al. Pedicled superior epigastric perforator flap for reconstruction of a soft tissue defect at the ventral thoracic wall. Eur J Plast Surg 2007;30: 141e6. 12. Duff CG, Aslam S, Griffiths RW. Fleur-de-Lys abdominoplastyda consecutive case series. BAPS 2003;56:557e66. 13. Migliori FC, Gabrielli A, Rizzo R, et al. Breast contouring in postbariatric patients: a technique selection algorithm. Obes Surg 2010;20:651e6. 14. Boyd JB, Taylor GI, Corlett R. The vascular territories of the superior epigastric and the deep inferior epigastric systems. Plast Reconstr Surg 1984;73:1e16. 15. Rhomberg M, Pu ¨lzl P, Piza-Katzer H. Single-stage abdominoplasty and mastopexy after weight loss following gastric banding. Obes Surg 2010;13:418e23. 16. Hamdi M, Van Landuyt K, Blondeel P, et al. Autologous breast augmentation with the lateral intercostal artery perforator flap in massive weight loss patients. J Plast Reconstr Aesthet Surg 2009;62:65e70. 17. Graf RM, Mansur AEC, Tenius FP, et al. Mastopexy after massive weight loss: Extended chest wallebased flap associated with a loop of pectoralis muscle. Aesth Plast Surg 2008;32:371e4.