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.
"This tissue can be raised off the latissimus and the serratus muscles, and there's adequate blood supply on the chest in
front to (affix) this back tissue over the pectoral muscle, under the breast above the nipple," he explains.
Frequently, weight-loss patients possess a long, flat distance between the axilla and the breast, he adds.
"When one uses this flap, one can sculpt in a nice transition or silhouette between the breast and axilla."
The thoracodorsal flap not only provides fill, he says, but it also gives curvature where it's very difficult to create in
standard breast reshaping procedures.
After this step, he says, "one can close the Wise pattern flaps and get a nice breast projection that seems to be maintained."
Results so far
To date, Dr. Hurwitz has performed this procedure in approximately 60 patients over a period of about three years.
"So far, it appears the inframammary fold holds up because I stitch the reverse abdominoplasty to the rib cage. And the breast
holds up because the spiral flap is helping it suspend in position. I believe any experienced plastic surgeon can learn the
spiral flap technique in a one-hour course."
As for complications, he reports that four of his patients have experienced fat necrosis, and two have required debriding.
"There have been some healing problems," Dr. Hurwitz says, "but nothing drastic such as serious infections."
Disclosure: Dr. Hurwitz reports no financial interests relevant to this article.
For more information:
www.hurwitzcenter.com
We subscribe to the HONcode principles of the Health On the Net Foundation