Augmentation mammaplasty by superolateral thoracic flap: a case report

One of the main issues in post-bariatric plastic surgery is to resect the dermolipomatous excess and to improve body contouring. Brachioplasty, abdominoplasty, cruroplasty, rhytidectomy, mammaplasty, and mastopexy are procedures that enhance self-esteem and reduce the health-related problems of these patients [1]. Ptosis and breast volume loss are common characteristics in women who have massively lost weight after bariatric procedures, and their correction is a frequent request [2].

Patients with massive weight loss also represent a group with distinct issues concerning the lateral chest wall [3]. The latter has the shape of a triangle with its apex at the axilla. It can be divided into three subunits: the axilla, breast, and chest wall. The lateral chest wall is intimately associated with the esthetics of the breast but is much neglected and rarely addressed as a separate unit [3]. Failure to address this area can have esthetic consequences and be a source of distress for patients, because the lateral chest wall and axilla cannot be easily hidden in certain clothing, such as bras and bathing suits.

In this article we describe a technique to address these issues. The lateral thoracic panicle juxtaposed to the breasts can easily be used as an adipofascial and superolateral thoracic (SLT) flap for breast augmentation. These SLT flaps on the lateral surface of the chest remain pedicled to their upper bloodstream and are buried subglandularly in the breast, creating an autologous breast augmentation.

We present the case of a young post-bariatric patient who received autologous breast augmentation with this lateral thoracic fat and skin excess at the same time as bilateral brachioplasty.

Plastic surgery after massive weight loss aims at resecting skin excess, facilitating personal hygiene to increase satisfaction with the body, improving sexual, social, and interpersonal relationships, increasing self-esteem, and providing better quality of life [4]. Patients with post-bariatric lateral chest wall deformities defined preoperatively and addressed directly have the greatest likelihood of obtaining a satisfactory esthetic outcome [3]. The augmentation mammaplasty technique by SLT flap described here allows the surgeon to perform symmetric augmentation of the breasts by using autologous tissue in patients with an unsightly excess of lateral thoracic skin and fat.

As the procedure is new, the patient stayed the first night after the operation in hospital in order to prevent any complications. However, given the low level of postoperative pain relieved by ropivacaine, the absence of expected complications with this type of surgery, and the lack of necessity to monitor the flap, outpatient hospitalization is probably sufficient.

Breast augmentation with or without mastopexy has regained its position as one of the most popular procedures in esthetic surgery. Various augmentation mastopexy techniques have been described to improve breast shape and increase their volume [5‐7]. They are considered difficult to plan with results that are not easy to predict [8‐10]. In our case, the placement of the breast flaps made it possible to reshape the breast sufficiently and to postpone classic mastopexy with its incumbent periareolar scars. However, our procedure cannot be performed at the same time as an inverted-T mastopexy in the event of major ptosis (Regnault stage IV). While augmentation with breast implants is still the simplest and safest method, complications such as capsular contracture, rippling, periprosthetic atrophy, implant deflation, and implant visibility and palpability may still occur. The use of autologous tissue for breast augmentation has several advantages over implants. Lateral thoracic tissue is often discarded, yet our technique allows it to be recycled for breast enhancement. There is no risk of capsular contracture or the other aforementioned problems, as the breasts are augmented with autologous tissue.

Breast augmentation with autologous tissue also creates a more natural feeling of having real breast tissue. Lipofilling can be performed subsequently if the volume of tissue is insufficient. SLT flap augmentation mammaplasty is not the only breast augmentation technique with autologous tissue. For example, mammaplasty by reverse abdominoplasty has been used successfully for rejuvenating the abdomen and the breast simultaneously [11‐15]. In the augmentation mammaplasty by reverse abdominoplasty (AMBRA) technique [11], the upper abdominal panicle juxtaposed inferiorly to the breasts is poised for easy repositioning as adipofascial flaps to allow augmentation mammaplasty. Other autologous techniques exist such as bilateral de-epithelialized transverse rectus abdominis musculocutaneous flaps, extended transverse rectus abdominis musculocutaneous flaps, pedicled perforator flaps, and autologous fat transplantation, which are considered to have the same level of performance as synthetic implants [16‐21].

Concerning the specific treatment of excess lateral thoracic fat and skin, few techniques have been reported to date. Some authors advocate an algorithmic approach to their surgical treatment, including transfer of autologous tissue, liposuction, fat injection, and direct excision. Cryolipolysis has also been used successfully to reduce discomfort from residual lateral chest wall fat in post-mastectomy patients [22]. The treatment of excess lateral thoracic fat and skin simultaneously with breast augmentation has been the subject of very few publications [23, 24].

Our technique is particularly adapted to E3 deformities in the classification of Bar-Meir et al. [3], involving an excess of both skin and fat of the lateral chest wall, usually involving all three subunits. Although initially designed for esthetic purposes, it has proven valuable for reconstructive purposes in appropriately selected cases [23]. Lateral thoracic tissue can be transferred to correct defects in treated or reconstructed breasts or to obtain symmetry. It has the advantage of combining autologous breast augmentation with an improvement in the lateral wall chest in a single procedure while keeping the groove under the breast. Its main theoretical risk is fat necrosis and cyst formation [25], hence the importance of preserving the external mammary vascular network for the vitality of the cutaneous sheath and breast fat, on the one hand, and of respecting the direct cutaneous perforators from the lateral thoracic, on the other. The flap is wide, which guarantees its vascular safety. The decision to lift the flap on a superior rather than an inferior external pedicle was considered carefully. This allows better anchoring of the scar and better fixation of the highly mobile fold under the breast in patients who have lost weight massively. This upper pedicle allows the flap to be turned over and folded to increase the projection of the breast.

Some authors [26] have demonstrated that the lateral thoracic region contains a fat compartment that is unique in its anatomical boundaries. Further vascularization of these lateral thoracic flaps has been described [24] and the pedicled fasciocutaneous flap can be based, as in this case, on direct cutaneous perforators from the lateral thoracic or intercostal arteries, or on septocutaneous perforators from the thoracodorsal or long thoracic arteries. According to the algorithm described by Levine et al. in 2015 [23] that facilitates the choice between the different pedicles, the flap must be centered over the fourth interspace if the tissue is needed for augmentation and if flap de-epithelialization is planned. Finally, the scar is less visible with this technique than with standard lateral thoracic dermolipectomy. Indeed, with lateral thoracic dermolipectomy, the vertical scar along the thorax is mandatory to remove any excess thoracic skin. Our technique allows the scars to be positioned advantageously on the external and submammary grooves, resulting in a much more esthetic appearance.

SLT flap augmentation mammaplasty is a simple new procedure for patients with lateral thoracic skin laxity and adiposity who desire autologous tissue breast augmentation with or without mastopexy combined with rejuvenation of the lateral chest wall. The increased lateral flank scarring in continuity with a simultaneous brachioplasty incision is well tolerated by patients, with the additional benefit of reducing flank fullness and avoiding the more visible scars associated with mastopexy.