To begin with, I'll have you know yours is a case of maximum difficulty, technical requirements and surgical performance. So I strongly recommend you seek a large number of opinions.I agree fat grafting is a real non sense in your case, I find it ridiculous and money and time waster, do seek better options.Going to your case, you have 2 associated issues around your breasts, both sequel from your massive weight loss and, peculiarly, both are adjacent to each other making a fake effect of double bubble breast, which is not real, it actually is a common ptotis (low, droopy) breast plus an adjacent crease of skin at the nearby tummy territory underneath the submammary crease.About your breast, they are low and droopy, as well as saggy, due to the weight loss, however... it is quite disputable the breast lift is a requirement, I'd say it si optional. Why so? Simple: the right breast has no ptosis or minimal one, and the left one has a moderate ptosis; in such scenario the massive scarring (vertical scar only in your case, NOT a extended scar mastopexy) of a breast lift could be, in your respectable and undisputable opinion, non justified versus acceptable, think about it, IMHO a breast lift is not a good trade off for you. However, you are born with low set breasts, which does not equal to droopy breasts, just happens the root and anchor of your breasts is lower than normal, just it, and this has no solution with a breast lift, the solution is other... Read with attention: the root and anchor point of a breast are the ligaments at the sumammary creast, this conditions the location of the breast and their level within the chest; well... due to your massive obesity your submammary crease ligaments have been stretched a lot and are incompetent and lower than they were before. This has 2 consequences:1. Your breasts have moved en bloc downwardsly a few cm's, making them set lower than you were born; this has NOTHING to do with breast ptosis (droopiness of nipples), it is just a low set of breasts due to flaccid support ligaments.2. The breasts implants (a must in your case) run a real risk, very very high one, of bottoming out due to the incompetence of the submammary crease ligaments; the implants might simply slide under the breast crease and end in greater part at the very right tummy, specially if the implants do not form a strong fixation to the ribcage, obviously (I have a lot of experience in ex obese cases, massively present in my area of practice).Solutions, following the same order:1. To raise the submammary creas the moving en block your breasts upwards we have to relocate the roots of your breasts at a higher and more proportionate point or level, rebuilding new ligaments and attachments to the ribcage by a technique called multipoint capsulorrhaphy, a common tool in revision mammaplasty specialists.2. To prevent the implants slide under the submammary crease's incompetent ligaments the approach has to be double: the former capsulorrhaphy will build neo-formed submammary crease attachments, firmer and safer, and additionally I recommend using the top-adherent in the world implants, the polyurethane coated implants (anatomical shaped better, since you are flat chested) which are able to for literally a biovelcro with your tissues, or alternatively macrotextured 5th generation implants which are also good acquiring adhesion, however the polyurethane coated ones are unparalleled in terms of self support.That is about your breasts, with the mere option to decide if you will go for breast lift or not.And now the back-trunk-chest flap or apron of hanging skin: it is forming a flaccid crease spanning from the back... affecting the armpit and side of the trunk... and also reaches the tummy as two hanging crescents underneath your breasts at the upper tummy; this all can be addressed at the same time, as follows:-a panniculectomy or skin-fat dermolipectomy removal from back to side of the chest... and at the time... -and as a continunous incision... a so called reverse abdominoplasty (google it), which is a technique solely used to get rid of some peculiar cases of upper tummy excess of skin (chalasis); obviously the scars of the reverse abdominoplasty are the same than the inverted T mastopexy at the horizontal part, and are compatible with the lower pole capsulorrhaphy, so... If you plan to do breast only I recommend:-no breast lift, lower creast multipoint capsulorrhaphy to raise en bloc the brest, and polyurethane coated anatomical implants (all feasible through areola approach) >>> difficulty 7 out of 10 scale in breast surgery-if you wish to add the lift I recoomend vertical scar Lejour mastopexy with the formerly mentioned duet of capsulorrhaphy + polyurethane implants >>> difficulty 9 out of 10 in breast surgeryHowever, if you wish to do the panniculectomy from back rolls and upper tummy inverse abdominoplasty associated with the breast... considering the common scars and the coincident and adjacent works, I recommend complete inverted T mastopexy (it is sensless and unfeasible to do vertical only if you'll get submammary crease incisions for the reverse tummy tuck) + polyurethane coated implants + back rolls panniculectomy + reverse abdominoplasty altogether >>> difficulty 10 out 10 in aesthetic surgery.You have to seek a lot of opinions, yours is a very complex and difficult case, with high chances of success in the right hands, I don't intend to discourage you, but to make you aware your is not a procedure for an average surgeon.If you wish better grounded opinion well lit, focused and standard images have to be assessed: frontal, both lateral and both oblique views, also from the back.
