Introduction INTRODUCTION besity is a global disease with epidemic proportion, O where severe cases are associated with multiple co- morbidities, which reduce life expectancy and markedly impair the quality of life (Marema et al., 2011). Management of obesity includes several modalities, such as; regulation of diet, exercise and the bariatric surgery. However, bariatric surgeries became the most expected modalities for sustained weight loss (Sebastian, 2008). Bariatric surgery or modified life style go a long way in diminishing the vast weight gain. Patients following these interventions usually undergo massive weight loss, which result in redundant tissues of lower trunk, upper back, breast, arms and thighs (Kwei et al., 2006). Massive weight loss (MWL) is defined as 50% or greater loss of excess weight (Shrivastava et al., 2008). The body contour deformities that develop in morbidly obese patients following massive weight loss involve almost all areas of body (Gusenoff et al., 2009). MWL can lead to considerable breast deformities commonly seen, including excess sagging of the skin, ptosis, loss or deficiency of breast volume secondary to atrophy and deflated flattened glands (Kwei et al., 2006). 1 Introduction After MWL, one of the stigmas that affect women is the remaining breast deformity. It's crucial to understand these deformities in fact. Management is done for aesthetic reasons. The breasts become flaccid and drooping. The upper pole is absent or flat. The striae of the skin are seen frequently due to loss of elasticity. Namely, the dermal elastin contents of skin matrix with no or poor ability to retract (Losken, 2010). Plastic surgeons have been involved in dealing with such kind of patients, who present that unique challenge that requires more than just the traditional techniques, because of the distribution and the quantity, as well as the quality of inelastic skin and fat left behind (Buckley, 2007). Techniques that are described for breast contouring include: breast augmentation, mastopexy or augmentation mastopexy. They are chosen according to the deformities that occur after MWL (Hurwitz, 2004). Mastopexy and augmentation mastopexy are the most frequently performed plastic surgical procedures for post bariatric surgery patients. Different techniques were described to achieve the goal mainly according to the severity of the deformities as regard volume loss, degrees of ptosis, nipple position and skin redundancy (Aly, 2006). The goal in female breast reshaping after MWL is to restore symmetry, projection, aethetic breast shape, medial and upper pole fullness, appropriately placed nipple areola complex (NAC) with minimal scarring (Bishara and Costagliola, 2012). 2 Aim of the Work AIM OF THE WORK he aim of the essay is to review the different modalities of T bariatric surgery and to spot light on the recent trends for breast reshaping following massive weight loss. 3 Anatomy of the Breast ANATOMY OF THE BREAST he breast develops as a skin appendage enclosed within the T superficial fascia. There is a bursa between the deep layer of this superficial fascia (on the deep surface of the breast) and the pectoral (deep) fascia of the thoracic wall. This retro mammary bursa is traversed by fibrous attachments, which are much denser inferiorly in nulliparous women. The bursa plane is relevant during surgical dissection in the retro glandular plane and contributes to the mobility of the breast on the chest wall (Romrell, 1991). The ideal youthful breast is teardrop in shape with gentle curvature of the lateral breast and a nipple areolar complex centered at the apex of the breast mound just above the inframammary fold (IMF) (Colwell et al., 2009) . With MWL, significant volume is lost and the ligamentous support of the breast is severely attenuated. The skin is inelastic and the dermis is relatively thin. This typically results in ptosis and a lowered IMF position. The lateral curvature of the breast is commonly blunted and blends gradually with the redundant axillary tissue. This aggregate of defects results in a ptotic, deflated breast with severe upper pole deficiency and no lateral definition (Colwell et al., 2009) (Fig. 1). 4 Anatomy of the Breast The mature female breast is located within the superficial fascia of the anterior thoracic wall and extends from the level of the second or third rib to the inframammary fold at approximately the sixth or seventh rib. Transversely, it extends from the lateral border of the sternum to the anterior axillary or midaxillary line (Romrell & Bland, 2006). Two-thirds of the base of the breast lies anterior to the pectoralis major muscle; the remainder lies anterior to the serratus anterior muscle. A small part may lie over the aponeurosis of the external oblique muscle (Velanovich, 1995). Figure (1): Sagittal cut section of the breast (Elsevier, 2008). 5 Anatomy of the Breast Superficial Fascia The superficial fascia is considered to be continued in an envelope of superficial fascia that is continuous with the superficial cervical and abdominal fascia (Gardner et al., 1986). A small amount of breast tissue travels toward the axilla in the majority of women. It is well known as the tail of Spence, and enters the axilla through an opening of the deep fascia along the medial axillary wall. This opening is the well- known hiatus of Langer (Donegan, 1980). The fascia completely envelops the breast lobes; each breast is formed by 15–20 lobes of glandular tissue. The lobes and lobules are separated by connective tissue, and septa. The subcutaneous tissue is thin or thick and travels deeply, forming the septa (Bland, 2007). Between the superficial fascia behind the gland and the deep fascia covering the pectoralis major muscle lays the retromammary space in which the lymphatics run (McMinn, 1999) . Deep Fascia The deep fascia, known as the deep pectoral fascia, envelops the pectoralis major muscle and travels below with the deep abdominal fascia. The deep fascia also attaches medially to the sternum, laterally and above to the clavicle and axillary fascia and inferiorly with the fascia of the serratus anterior. A 6 Anatomy of the Breast posterior extension of this fascia is continuous with the fascia of the latissimus dorsi and forms the so-called suspensory ligament of the axilla (Colborn & Skandalakis, 1993). The retro mammary space is a bloodless plane containing some loose areolar tissue, small blood vessels and posterior suspensory ligaments which extend from the deep surface of breast to the deep pectoral fascia (Iglehart, 1991). Another bloodless plane lies just deep to the dermis. This plane is 2-3 mm deep to the skin. Fibrous tissue strands extend from the deep fascia to the skin. These are called the ligaments of Asteley Cooper, which are responsible for the protuberant appearance of the young female breast. With age, they become atrophic and allow the breast to drop (Colborn & Skandalakis, 1993) . These ligaments are believed to be essential to breast support, and the preservation of the relationship between the gland and the overlying skin. It provides the rationale for reduction techniques that minimize skin undermining, theoretically helping in postoperative glandular ptosis (Ricbourg, 1992). The breast parenchyma It consists of a branching duct system of 15 to 20 lobes, which radiate from the nipple and bound together by fairly dense connective tissue septa, the interlobular connective 7 Anatomy of the Breast tissue. Each lobe is roughly pyramidal in shape with the apex toward the nipple. Bands of connective tissue, the suspensory ligaments, extend from the interlobular connective tissue to attach to the dermis (McVay, 1984). Each ductal system drains through a separate main duct, the lactiferous duct, which terminates and exits the breast at the nipple via a secretory pore. Immediately deep to the areola, each lactiferous duct dilates to form the lactiferous sinus, in which milk can accumulate, and beyond the sinus extends through successive branches of diminishing size, the large and intermediate (interlobular) ducts (Iglehart, 1991). The ducts are continuous with the functional units of the breast, the terminal duct lobular units (TDLU). The TDLU consists of the intralobular duct, along whose lumen end protrude blunt or round saccules called ductules, which differentiate into the secretory units or acini during lactation. Individual lobes vary greatly in size and typically about less than half enlarge to become functional during lactation. The TDLUs are embedded in specialized, hormonally responsive connective tissue stroma, the intralobular stroma (McVay, 1984). For the anatomical location and description of tumors and cysts, the surface of the breast is divided into four quadrants (Fig 2) (Ahya et al., 2001). 8 Anatomy of the Breast Figure (2): Quadrants of the breast (Ahya et al., 2001). The breast contains adipose tissue, as well as glandular, neurovascular, and connective tissue components. The amount of fatty tissue is extremely variable and depends on the patient's weight, genetics, age, and hormonal status (Lejour, 1998). Nipple –Areola complex The nipple and aerola are located at the 4 th intercostals space slightly lateral to the midclavicular line with the nipple facing slightly outward and upwards, and is composed of 15-25 irregular lobes that terminate as lactiferous ducts in the nipple (Bloom and Fawcett, 1975). 9 Anatomy of the Breast Arterial blood supply: The arterial blood supply to the breast is rich and varied, with overlapping territories, allowing diverse reduction techniques to be safely performed. It depends on the subdermal plexus, which is in communication with deeper underlying vessels supplying the breast parenchyma. The reduction will be successful as long as sufficient number of vessels remain to support the breast tissue, regardless of the direction from which the blood supply comes (Dowden, 1999). The major blood supply of the breast comes from superiomedial perforating branches of the internal mammary artery accounting for around 60%. Then comes the lateral branches of the posterior intercostal arteries, and branches from the axillary artery (Romrell, 1991) .