This is an example of a patient who has lost 170 pounds status post Roux-en-Y gastroplasty (gastric bypass surgical procedure) two years ago. She has lost more than half of entire body weight, approximately 165 pounds, weighing in at about 310 pounds preoperatively to her Roux-en-Y gastroplasty. As expected, her skin is tremendously lax and there is grade 3 ptosis. The preoperative photographs show skin laxity from the breast extending to the lateral anterior axillary line as well as skin in the lower abdominal area. She will require a panniculectomy secondary stage.
The patient’s past medical history is significant for history of iron deficiency anemia, which is associated with her Roux-en-Y gastroplasty with malabsorption of iron. She also has a history of esophageal ulceration and has been cleared by Gastroenterology with no active bleeding at this time.
The patient was brought to the operating room at which time under general anesthesia and dual plane technique, a 500 cc high profile saline implant was filled to 580 cc to regain fullness of the upper pole and to reduce visible rippling, with a style 68 high profile Natrelle saline implant.
A formal mastopexy using the inferior pedicle Wise-pattern technique was marked out and a significant amount of skin was de-epithelialized on each breast. Subsequently, the flaps were brought together and her postoperative day one photograph shows excellent symmetry with superior fullness of the upper pole, good cleavage and moderate swelling as expected.
Patients who have massive weight loss will undergo a combination augmentation and mastopexy procedure. These can safely be performed at the same time as long as the physician is a Board Certified Plastic and Reconstructive Surgeon and has experience with the vascularity of the pedicle and the nipple areolar complex.
This preoperative photograph shows a patient with significant asymmetry of the inframammary fold. The inframammary fold is one of the most important, if not the most important, landmarks on the breast when performing breast augmentation surgery.
Notably, on this patient her right inframammary fold is significantly lower than the left and also notable is a larger nipple areolar complex on the right and breast volume. As a result, it is extremely important that the inframammary fold on the right not be lowered so as to prevent bottoming out which would occur even if the implant is placed in its normal natural position. During surgery, the inframammary fold was not violated and the implant was placed approximately 1.1 cm above the inframammary fold in order to regain symmetry with the left. The left inframammary fold will be slightly lowered to regain symmetry with the right and 20 cc more fluid is placed in the high profile Natrelle saline implant on the left to regain symmetry to the contralateral side.
Inframammary folds are difficult to correct once asymmetry occurs postoperatively. In a patient like this, preoperative evaluation and screening is vital to prevent what can easily be an asymmetry postoperatively with the right fold positioned lower. The inframammary fold attachment should not be violated on the right side and the implant will be placed superiorly and an upper pole band will be placed for only five days in order to prevent increased external inferior pressure which could lead to severe bottoming out.
SEVERE BAKER IV CAPSULAR CONTRACTURE
The patient below presents with severe Baker IV capsular contracture with encapsulation. Baker IV capsular contractures are usually associated with painful hardened breasts with severe distortion and may be associated with coldness and loss of sensitivity as well. This patient presents with severe encapsulation and hardening with a Baker IV capsular contracture and slight asymmetry. Through a periareolar approach, the patient underwent an open periprosthetic capsulectomy, circumferential open capsulotomy, removal and replacement with 320 filled to 375 cc high profile saline right, 325 to 355 left, in order to regain symmetry. Her postoperative results show softening of her breast bilaterally, well-healed periareolar scars and there is softening of the lateral and inferolateral portions of each breast that the upper pole scar tissue contracture has now been released, especially in the axillary region.
Open capsulectomies conservatively with circumferential open capsulotomies should be performed on patients with Baker IV capsular contractures as noted in this example.
Patients do present in their teenage years for breast reduction surgery. These young women often have the same symptoms associated with bilateral breast hypertrophy, including large pendulous breasts with back pain, neck pain, grooving along the shoulder blades; however intertriginous rashes are less common. There is also the emotional difficult psychological torment of having disproportionately large breasts at a young age, especially during the puberty years in which impressions in high school years are very important.
Recently, I had a patient present with 36DDD breasts and desired to reduce down to a small B. The patient underwent the inferior pedicle Wise-pattern technique, approximately 280 to 320 grams of tissue was removed bilaterally, bringing the patient down to a small B. It is important that all patients under the age of 18, as this patient was 17, must have a parental guardian, and we sit with the patients a minimum of two times with their parental guardian on two separate dates to review all consent forms. Scarring is extremely unpredictable and therefore photographs of after postoperative breast reductions should be reviewed with the patient and the patient’s legal guardian. Consent forms should be reviewed with the patient and the guardian in detail and signed accordingly. Although patients at 17 may continue to develop further breast development for the next four to five years, at times reducing the breast at that age is the correct avenue, especially with disabling over-abundance of breast tissue causing chronic back pain and the emotional physical torment that occurs during their growing years.