Modern Plastic Surgery, 2013, 3, 123-127
http://dx.doi.org/10.4236/mps.2013.34025 Published Online October 2013 (http://www.scirp.org/journal/mps) 123
Retrospective: Mammoplasty with Prosthesis after
Video-Assisted Bariatric Surgery with Transverse
Bipediculated Flap*
José Humberto Cardoso Resende1, Rossano Kepler Alvim Fiorelli2
1Plastic Surgery, Federal Hospital for the Civil Servants of the State of Rio de Janeiro, Rio de Janeiro, Brazil; 2General Surgery,
Federal University of the State of Rio de Janeiro, Rio de Janeiro, Brazil.
Received August 23rd, 2013; revised September 21st, 2013; accepted September 28th, 2013
Copyright © 2013 José Humberto Cardoso Resende, Rossano Kepler Alvim Fiorelli. This is an open access article distributed under
the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided
the original work is properly cited.
ABSTRACT
Objective: To assess the rate of mammary prosthesis extrusion after mammoplasty with prosthesis implantation, to
verify the resulting shape and the degree of patient satisfaction after the use of a transverse bipediculated flap with lat-
eral irrigations. Methods: 30 patients with a weight loss of 50 kg on average after video-assisted bariatric surgery, with
ptosis and excessive volumes, who underwent mammoplasty with prosthesis placement with volumes ranging from 190
to 260 cc, using a transverse flap with th e aim of anchoring the silicone prosthesis. Results: In the patients’ evaluation,
the few postoperative complaints did not amount to complications. Pains were minimal and the discomfort with the
prosthesis was acceptable. Conclusion: the transverse flap, in addition to acting as the best anchor among the existing
flaps for implanted prostheses, provided a youthful, natural, anatomical, aesthetic and longer lasting appearance for the
breasts.
Keywords: Mammoplasty; Mastoplasty with Prosthesis; Non-Aesthetic Female Mammary Plastic Surgery;
Post-Bariatric Mammoplasty
1. Introduction
This study of transverse flaps in mammoplasties was
guided by an assessment of results in order to decrease
the rate of extrusion of mammary prostheses used to give
the breasts a better shape, lifting them up to place them
in a better anatomical position, with a better shape and
consistency, reducing the number of repeat operations or
a constant exchange of prostheses [1].
Patients who undergo bariatric surgery lose weight in a
short time [2], causing tissue to sag, primarily that of th e
skin, causing esthetic, interpersonal problems and low
self-esteem [3].
The transverse flap is irrigated at the medial portion by
branches of the internal thoracic or mammary arteries,
and on the lateral portion by branches of the external
thoracic and axillary arteries. With th e detachment of the
upper pectoralis major in order to form a pocket where
the prosthesis will be placed, the flap receives little irri-
gation from intercostal arteries [4].
Other techniques may serve the same purpose [5], but
the transverse flap provides the prosthesis safety and
protection against possible extrusions, which could occur
at the joint of the inverted “T” scar without the flap.
Thus, this study aimed at evaluating and demonstrat-
ing a new technique that removes excess skin due to
large weight loss using the transverse flap to protect the
placement of the silicone prosthesis.
2. Method
For this study, we selected 30 patients that had under-
gone video-assisted bariatric surgery, aged between 30
and 55 years, regardless of color, religion or other op-
tions, all with a weight loss above 30 kg. They were op-
erated after six (6) months of weight maintenance and a
minimum of t wo (2) years after bariatric surgery.
They attended the Workshop for the Obese, which su-
pervises the nutritional aspect, answers all question s rela-
tive to the necessary plastic surgeries, assuring patients
*Final monograph for the profess ional master’s degree in medicine.

Retrospective: Mammoplasty with Prosthesis after Video-Assisted Bariatric Surgery
with Transverse Bipediculated Flap
124
and boosting the will power of candidates for body re-
pair.
The proposed surgery consists in marking the inverted
“T” technique in final form. Points A-D and E (Figure 1)
are previously marked [6] and the entire area is included
within the markings to be decorticated, thus taking ad-
vantage of all existing tissues except the skin. The anes-
thetic infiltration is carried out along the entire marking
route (Figure 2). Next, the marking is performed with an
Areola & Keyhole Marker (Figure 3). After decortica-
tion, hemostasis and marking of the superior flap (Figure
4), the detachment above the pectoralis major is per-
formed, for placement of the prosthesis (Figure 5). Then
the superior flap is released, maintaining the medial
pedicle larger than the lateral one to irrigate the areolas,
separating the superior flap that contains the areo-
lar-papillary complex of the transverse flap ready and
freed. After inserting the prosthesis [7], the flap’s inferior
base is attached to the pectoralis major fascia 5 cm above
the bottom edge of the inverted “T” (Figure 6). All blood
tissues are approximated (Figure 7). Finally, the skin is
sutured and the areolar-papillary complex is reimplanted
(Figure 8). Stitches are made with intradermally ab-
sorbable sutures. The patient is released in 24 hours; re-
visions are made twice a week until the second month,
and monthly monitoring is carried out for six (6) months.
(Figures 9-16 show a retrospective of pre- and post-
operative phases of used techniques).
An assessment instrument was developed and applied
at the end of the sixth month after surgery, to which all
patients responded subjectively, with 0-10 scores, where
the highest number represents greater satisfaction with
the surgery’s outcome (Figure 17).
3. Results
When the surgeries were evaluated, it was found that
postoperatively there is greater hardening of the breasts,
without capsular contracture of the prostheses. Less de-
scensus (natural drooping or sagging of the breast with
Figure 1. Pre-operational stage with technique’s markings.
Figure 2. Infiltration of incisions.
Figure 3. Marking of the areolar-papillary complex.
Figure 4. Decortication, hemostasis and marking of the su-
perior flap.
Figure 5. Placement of silicone prosthesis.

Retrospective: Mammoplasty with Prosthesis after Video-Assisted Bariatric Surgery
with Transverse Bipediculated Flap 125
Figure 6. Fixation of transverse flap in the fascia of the
pectoralis major.
Figure 7. Approximation of blood tissues.
Figure 8. Reimplantation of the areolar-papillary complex.
Figure 9. Pre-operational stage front—patient A. T., 35
years of age and weight loss of 55 kg.
Figure 10. Post-operational stage front after 6 months, pa-
tient A. T.
Figure 11. Pre-operational stage profile—patient A. T.
Figure 12. Post-operational stage profile after 6 months,
patient A. T.
Fi gure 13. Pre-operational stage front-patient M. S. 52 years
of age and weight loss of 62 kg.

Retrospective: Mammoplasty with Prosthesis after Video-Assisted Bariatric Surgery
with Transverse Bipediculated Flap
126
Figure 14. Post-operational stage front after 6 months, pa-
tient M. S.
Figure 15. Pre-operational stage profile—patient M. S.
Figure 16. Post-operation al stage profile com 6 after 6 months,
patient M. S.
Figure 17. Graph representing degree of satisfaction in
percentage points.
time) was also observed than with other techniques that
have been used [8]. No cases of prosthetic extrusion were
found [9]. The surgeries were performed in less than
three hours. As the scars are smaller, the degree of satis-
faction was excellent and social reintegration was com-
plete. Thus, 97% of patients responded that they were
happy and evaluated th eir satisfaction with 10 points. 2 %
answered that they were happy, but still expected more
plastic surgeries in the rest of their bodies. 1% could not
answer, despite being happy with the surgery performed.
4. Discussion
In patients who lost weight as a result of bariatric surgery,
there is distress and psychological discomfort resulting
from excess skin that exhibits excessive ptosis of the
breasts and all other parts of the body [3]. The flaccidity
is so severe that whatever the selected technique the
breasts will not be anatomical without the placement of
silicone breast implants since they have no glandular
volume [10]. There is a large difference between those
who have lost weight of their own free will, losing 30 kg,
and patients with a weight loss of over 50 kg for example
[10]. With bariatric surgery, weight loss is not protracted,
it takes place gradually, but at a much faster rate. It has
also been noted that the flaccidity is permanent, leading
surgeons to select techniques that remove far more skin
than cellular tissue, in order not to induce major detach-
ments [11]. In the long run, after bariatric surgery, no
mammoplastic technique will meet patients’ desire to
possess hardened breasts, with anatomical and durable
shapes. The flap with inferior pedicle [12] used in mam-
moplasties has shown to be a great surgical option with
excellent results. However, this work [13] does not de-
scribe its use in post-bariatr ic breast surgery where ptosis
has become extremely severe tending to impermanent
results. On the other hand, flaps with superior pedicle [4]
are best used in reduction mammoplasties, not specifi-
cally for post-bariatric cases. Mastopexy cases have been
reported with superior pedicle flaps and silicone implants
with only 7.35% of cases with ptosis reincidence [9],
which is considered an excellent result. Inferior flaps
described as dermal pyramids [14] are another option for
good aesthetic results, wh en resections were between 200
gr to 3350 gr in each breast. It must be pointed out that,
in evaluations, there was one case of a free graft detached
from the areolar-papillary complex, owing to the long
distance between the areolar complex and point “A” for
reimplantation. Thus, possible tissue sufferance or even
necrosis are avoided [15]. The relevance of using flaps to
improve mammal symmetry, including post-mastectomy
cases due to cancer, was verified [2]. It also provides an
option for the use of the thoracic wall flap in vertical
mammoplasties [16]. The best indications are for cases of
reductive mammoplasties, whereas it may not apply to
post-bariatric surgery cases, owing to the excess skin and
little glandular tissue to be removed. In all cases, in this
retrospective, the placement of silicone tape on scars was
advised for the prev ention of keloids.
The transverse bipediculated flap presented in this

Retrospective: Mammoplasty with Prosthesis after Video-Assisted Bariatric Surgery
with Transverse Bipediculated Flap
127
study was performed to serve as an anchor belt for the
silicone prostheses implanted, preventing its extrusion,
thereby improving the shape of the breast and making the
result longer lasting.
5. Conclusion
Comparing cases and reviewing the literature, we con-
clude that the transverse bipediculated flap used in post-
bariatric surgery of mammoplasty mastopexy cases will
be another option for the surgeon, in view of the chal-
lenges that deformities pose to us. In our retrospective
review , the good shape ex hibited by the brea sts, minima l
complications, such as ecchymosis and erythema, and no
cases of prosthesis extrusion were noted. It also demon-
strated that the flap can be used in mastopexy cases to
correct ptosis, even if not caused by post-bariatric sur-
gery slimming.
6. Acknowledgements
To Prof. Dr. Rossano Kepler Alvim Fiorelli, UNIRIO
M.Sc. supervisor, to Paulo Marcos Queiroz Resende and
Filipe Algayer Casagrande for th eir collaboration.
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