In the massive weight loss (MWL) patient, the upper body and breast must be treated together for optimizing results because the two regions are adjacent and one affects the other. After MWL, upper back rolls are a common annoyance, on the sides and back. Extending around to the front, the upper back rolls become continuous with the lateral (outside) of the sagging breast. Even patients who have been large-breasted their whole life can find themselves with excess volume loss and "pancake"-like flattening of the breasts. The breasts can be completely deflated, with only the significant skin excess contributing to volume as the patients roll or stuff the excess skin into a bra. Even if a C-cup is required to hold the sagging breasts, this is a false sense of size if the volume is comprised mainly of skin rather than breast tissue or fat.
Treatment of the back rolls cannot be adequately performed by liposuction alone. Open removal of the excess skin is required, usually with a scar extending within the bra-line around the back, sometimes all the way across the back. The sagging breasts are treated with a mastopexy procedure, meaning a breast lift. The lift usually requires incisions around the nipple and under the breast. The nipple is relocated much higher to a normal position. The skin excess is reduced. Many such patients will end up with inadequate volume with a breast lift - only. They require some form of breast augmentation.
Breast augmentation is done in most non-MWL patients with breast implants. However, we have generally been disappointed with procedures that involve implants as the only means of breast enlargement in the MWL patient. Instead, we usually prefer using the patient's own tissues (the side and back roll tissues) and rotating them into the breasts to act as breast implants. Our technique, developed here at BIDMC, uses the ICAP flap (meaning intercostal artery perforator) to allow us to place the tissue where it is most needed in the breast. This video shows the planning of the upper body lift.