Abdominoplasty/Liposuction 01-22 Flashcards
A 26-year-old woman presents for buttock augmentation. BMI is 19.1 kg/m2. Due to lack of donor sites for autologous fat transfer, gluteal augmentation with silicone implants is planned. Which of the following is the most common complication following this procedure?
A) Fat embolism
B) Hematoma
C) Infection
D) Seroma
E) Wound dehiscence
The correct response is Option E.
Silicone implants can be used to augment the buttocks, especially when there are limited donor sites for autologous fat transfer. The use of silicone implants confers a greater risk for perioperative complications than fat grafting alone. The most common complication is wound dehiscence, which has been reported to occur in 9.6% of patients. Efforts to reduce wound complications have included the use of bilateral parasacral incisions as opposed to one gluteal cleft incision. Complications are more common after subfascial placement than after intra- or submuscular placement. Seroma, infection, and hematoma occur in 4.6, 1.9, and 0.6% of patients, respectively. Fat embolus is a rare but dangerous complication associated with fat grafting, not silicone implants.
A 35-year-old woman presents with midline wound dehiscence with tissue necrosis 2 weeks after undergoing uneventful abdominoplasty. A photograph is shown. The patient reports that she did not stop smoking before surgery as instructed. Which of the following mechanisms has the greatest impact on delayed wound healing in this patient?
A) Decreased catecholamine production
B) Decreased leukocyte function
C) Decreased levels of hemoglobin
D) Increased fibrinogen production
E) Increased microvascular vasoconstriction
The correct response is Option E.
Cigarette smoking is a leading cause of preventable death and disability in the United States. Over the past 20 years, several studies have demonstrated an increased risk of postoperative complications following plastic surgical procedures including rhytidectomy, breast reconstruction, digital replantation, muscle flaps, and body contouring procedures.
Tobacco smoke is a complex mix of particulate matter, volatile acids, and gases. There are over 4000 different compounds in cigarette smoke, many of which are toxic, mutagenic, and carcinogenic. Tobacco-induced vasoconstriction is mediated directly and indirectly by nicotine, a colorless, odorless, and poisonous alkaloid.
Elevated cellular levels of nicotine cause direct microvascular vasoconstriction. Indirect pathways of vasoconstriction include the enhancement of thromboxane A2 and stimulation of catecholamine release. Random skin flaps, such as abdominoplasty, rhytidectomy, and mastectomy flaps, are predominantly supplied by the subdermal plexus, which is very sensitive to sympathomimetic agonists such as catecholamines.
Smoking also increases carboxyhemoglobin levels, which shifts the oxygen-hemoglobin saturation curve to the left. The net result is decreased oxygen-carrying capacity by direct competitive inhibition from carbon monoxide. Other effects caused by smoking include decreased prostaglandin I2 (prostacyclin) production, increased platelet aggregation and blood viscosity, decreased collagen production, decreased red blood cell deformability, increased fibrinogen production, and decreased leukocyte function (mediated by hydrogen cyanide). The net effect is a prothrombogenic state with impaired inflammation that also contributes to slow wound healing. Although fibrinogen production is increased and leukocyte function is reduced, the primary mechanism by which wound healing is impaired is related to the nicotine-induced vasoconstriction of the subdermal plexus.
Rhytidectomy patients who smoke are 12.5 times more likely to develop skin necrosis compared with nonsmokers. One study showed a 47.9% rate of wound healing problems in abdominoplasty patients who smoked compared with 14.8% in nonsmokers. Another large study of patients undergoing free transverse rectus abdominis musculocutaneous (TRAM) breast reconstruction showed no difference in free flap survival in those patients who smoked, but the smoking population had a significantly higher rate of mastectomy skin flap loss, abdominal donor site complications, and hernias. Active smoking is not only a risk factor for wound complications, but the overall number of cigarettes smoked in a lifetime can affect the rate of wound infections. One study showed a risk for infection of 14.3% in patients who claimed to have stopped smoking 4 weeks before their abdominoplasty compared with 1.2% of nonsmokers. This study also showed higher infection rates were associated with more years of smoking, a higher number of cigarettes smoked per day, and a higher number of estimated cigarettes smoked during a lifetime. Current recommendations for smokers who desire elective cosmetic surgery are to avoid smoking and all nicotine products for 2 to 4 weeks before and after surgery.
A 41-year-old woman is evaluated for abdominoplasty and liposuction in the outpatient setting. Surgery is expected to take 2 hours. Caprini score is 2. Which of the following is the approximate risk for venous thromboembolism in this patient?
A) 1%
B) 10%
C) 15%
D) 20%
E) 25%
The correct response is Option A.
There have been many studies aimed at risk stratification for venous thromboembolism (VTE) in plastic surgery patients. Despite this, the topic remains controversial. There are no specific recommendations for patients undergoing abdominoplasty and liposuction; as such, management strategies are case-specific and vary widely between practitioners. It is, however, well-known that abdominoplasty has a higher risk for VTE events compared with other procedures. Though the specific rates of VTE vary per study, the average risk is about 1%. Interestingly, in one study using Internet Based Quality Assurance Program data, the rate was found to be 0.15%. This particular study did not find an increased incidence of VTE in those undergoing multiple procedures, and this has been corroborated by multiple authors. That being said, it is important to calculate a Caprini score and treat each patient on a case-by-case basis. At the least, sequential compression devices should be used for every patient undergoing abdominoplasty, and for those with higher Caprini scores, one should consider using low molecular weight heparin or unfractionated heparin for VTE prophylaxis. The risks of 10%, 15%, 20%, and 25% are too high, and thus they are incorrect.
A patient who underwent cryolipolysis develops paradoxical adipose hyperplasia (PAH). Which of the following is the minimum amount of time that should pass after the procedure before surgically treating the PAH?
A) 1 Month
B) 3 Months
C) 6 Months
D) 1 Year
E) 2 Years
The correct response is Option C.
Paradoxical adipose hyperplasia is a rare complication of cryolipolysis that may occur more frequently than in the manufacturer’s reported data. Treatment is best delayed until the affected area has softened, which normally occurs in 6 to 9 months after the initial cryolipolysis procedure. Power-assisted liposuction is the preferred method of treatment, but in some cases, abdominoplasty may be necessary. Secondary treatments might be needed for recurrence or persistent bulge.
A 45-year-old woman who underwent lipoabdominoplasty 6 weeks ago comes to the office. She is pleased with the contour and the low placement of the scar; however, she has persistent pain along the inferior portion of the incision with numbness in the thigh. On examination, pain is elicited with light pinching or pressure over the affected area along the lower portion of the incision, with a positive Tinel sign present along the anterior superior iliac spine. Nerve entrapment is suspected. Which of the following nerves is most likely involved?
A) Anterior femoral cutaneous
B) Genitofemoral
C) Ilioinguinal
D) Lateral femoral cutaneous
E) Lateral thoracic
The correct response is Option D.
Meralgia paresthetica is the term for compression of a branch of the nerves that gives normal sensation to the lateral upper thigh. In a review of the literature by Ducic et al., the lateral femoral cutaneous nerve (LFCN) was the nerve most commonly injured after abdominoplasty, with the pooled risk calculated for injury to the LFCN being 1.36% (n = 28/2061 patients). The LFCN is best protected by understanding the relationship with the anterior superior iliac spine (ASIS) and by leaving a swath of undissected loose areolar tissue covering this region. Overly wide dissection, blind dissection between planes, and randomly placed “deep bites” of tissue (during muscle plication or near the ASIS) all have the potential to create direct nerve injury. The ilioinguinal, anterior femoral cutaneous, lateral thoracic, genitofemoral nerves can be injured during an abdominoplasty; however, none fit the anatomic location and nerve distribution described.
A 36-year-old woman, gravida 3, para 3, presents to the office for consultation for abdominal contouring. Current BMI is 22.5 kg/m2. She has lost 20 lb (9 kg) since the birth of her last child 2 years ago, and her weight has been stable for the past 6 months. Examination of the abdomen shows lipodystrophy in the lower abdomen with skin laxity both above and below the umbilicus, and a small overhanging panniculus below the umbilicus. She has mild diastasis recti with no hernias noted. Which of the following is the most appropriate treatment for this patient?
A) Abdominoplasty with rectus plication
B) Fleur-de-lis abdominoplasty
C) Radiofrequency skin tightening
D) Reverse abdominoplasty
E) Suction-assisted liposuction
The correct response is Option A.
The best choice for this patient will address all of her concerns and physical examination findings. These findings include upper and lower abdominal skin laxity, lower abdominal lipodystrophy, and rectus diastasis.
Radiofrequency skin tightening is not reliable or predictable. It will not address the concerns with lipodystrophy or narrow the rectus diastasis. Additionally, of note, there is little higher-level evidence in peer-reviewed literature demonstrating the effects or benefits of radiofrequency for skin tightening in the abdomen.
Suction-assisted liposuction will address the lower abdominal lipodystrophy but will not address the supraumbilical skin laxity or the rectus diastasis. Reverse abdominoplasty will primarily address the skin laxity above the umbilicus but is not as helpful for laxity below the umbilicus.
The best choice for this patient among the options listed is an abdominoplasty with rectus plication. This will address all her areas of concern. A fleur-de-lis abdominoplasty is typically indicated in a patient who has sustained massive weight loss and has both horizontal and vertical truncal laxity. The trade-off of a noticeable vertical scar with clothing such as a bikini would not be worth the benefit of any additional skin tightening, and it is typically not indicated in the typical postpartum woman with a BMI in the normal range who does not have a history of massive weight loss.
A 26-year-old man with history of lipodystrophy of the abdomen and flanks undergoes suction-assisted lipectomy under general anesthesia. The surgeon anticipates 3 L of lipoaspirate. In the superwet technique, which of the following is the most appropriate amount of fluid for the patient to receive in the form of subcutaneous tissue infiltration?
A) 0 mL
B) 900 mL
C) 1500 mL
D) 3000 mL
E) 6000 mL
The correct response is Option D.
Originally, liposuction was performed without wetting solutions. However, this technique was associated with reported estimated blood loss of up to 45% of aspirate. Infiltrating wetting solutions with a base of normal saline or Ringer’s lactate with additives (epinephrine and lidocaine) prior to suctioning improves hemostasis and pain control. The current options for wetting solutions are dry, wet, superwet, and tumescent. The dry technique is rarely employed, and no wetting solution is infused. The wet technique employs injecting a standard 200 to 300 mL per anatomic area to be treated, irrespective of the anticipated lipoaspirate. The superwet technique is predicated on a 1:1 ratio of instilling 1 mL of solution per 1 mL of aspirate. True tumescent infiltration involves infiltration at a ratio of 2:1 to 3:1 of wetting solution per mL of expected lipoaspirate.
0 mL is used for a dry technique. 900 mL is used for a wet technique. 1500 mL does not fall into any category. 6000 mL is used in a tumescent technique.
A 45-year-old woman is undergoing an abdominoplasty. The plastic surgeon plans to perform a regional block to target the anterior divisions of the spinal segmental nerves. Which of the following is the most appropriate abdominal plane for injection of the numbing medication?
A) Between the external oblique muscle and the internal oblique muscle
B) Between the internal oblique muscle and the transversus abdominis muscle
C) Between the skin and the external oblique muscle
D) Between the transversus abdominis muscle and the peritoneum
The correct response is Option B.
A transversus abdominis plane (TAP) block is best performed between the internal oblique muscle and the transversus abdominis muscle, and it is often used during abdominoplasty surgery and abdominal wall reconstruction surgery.
The three major muscles of the anterolateral abdominal wall are the external oblique muscle, the internal oblique muscle, and the transversus abdominis muscle. The innervation of the anterolateral abdominal wall is provided by the thoracoabdominal nerves and the ilioinguinal and iliohypogastric nerves. The TAP block targets these nerves in the plane between the internal oblique muscle and the transversus abdominis muscle.
A 38-year-old woman, gravida 2, para 2, presents with abdominal laxity and rectus diastasis. An abdominoplasty is planned, utilizing a transversus abdominis plane block for pain control. Which of the following dermatomes will demonstrate the densest level of anesthesia?
A) L2
B) L5
C) T3
D) T6
E) T10
The correct response is Option E.
The transversus abdominis plane (TAP) block is a regional anesthetic that blocks sensory afferent nerve fibers that supply the anterior/lateral abdominal wall dermatomes of T7 to L1. The T10 dermatome innervates the abdominal wall at the level of the umbilicus and would demonstrate the highest level of anesthesia out of the dermatome levels listed above. The sensory nerves travel below the internal oblique muscle in the plane above the transversus abdominis muscle. Traditionally, the technique is performed blindly by placing a needle through the triangle of Petit posteriorly until the needle reaches the TAP. Once in the appropriate plane, 20 mL of a long-acting local anesthetic, such as bupivacaine, are injected. More recent modifications include the use of ultrasound guidance to optimize precise placement and the use of diluted long-acting multivesicular liposomal bupivacaine (Exparel). Several studies have demonstrated the benefits of a TAP block during abdominal surgery. These benefits include decreased pain, opioid use, and nausea/vomiting, as well as faster return of bowel function. Complications include potential systemic toxicity due to dose of anesthetic delivered/inadvertent intravascular injection and intraperitoneal injection with possible injury to intra-abdominal organs such as the liver or spleen.
A 35-year-old woman presents for liposuction of the anterior and posterior trunk under general anesthesia. Using a super-wet infiltration technique, 4 L of fat/liquid will be aspirated. The plastic surgeon plans to administer tranexamic acid 10 mg/kg intravenously as an off-label treatment to further reduce intraoperative blood loss. Which of the following is a contraindication to the use of tranexamic acid?
A) Active menorrhagia
B) Color blindness
C) Elevated liver enzymes
D) Known allergy to milk products
E) von Willebrand disease
The correct response is Option B.
Tranexamic acid (TXA) is a powerful antifibrinolytic agent that can be administered intravenously, orally, topically, or by injection, mixed with local anesthetic. While approved by the Food and Drug Administration for the treatment of heavy menstrual bleeding, it has many off-label uses in surgery, including cardiac surgery, spinal surgery, total-knee arthroplasty, and elective cesarean delivery. In plastic surgery, preliminary studies have shown TXA to be effective in reducing blood loss in craniofacial surgery, orthognathic surgery, and reduction mammaplasty. In aesthetic surgery, it has been found to be useful in face lift, rhinoplasty, and liposuction to reduce bleeding and hematoma. In one randomized study of super wet liposuction, blood loss in the liposuction aspirate was reduced by 37% in the TXA-treated group.
Transient changes in color vision have been reported following administration of TXA, and ophthalmalogic monitoring, including color vision assessment, should be a part of care for patients who receive TXA for longer than a few days as a part of toxicity monitoring. Because patients with color blindness cannot be monitored for changes, the manufacturer lists color blindness as a contraindication to TXA use.
Other contraindications to TXA use include known allergy to TXA, intracranial bleeding, known history of venous or arterial thromboembolism or active thromboembolic disease. Renal insufficiency may require dosage adjustment.
TXA can be used in the treatment of certain bleeding disorders, including von Willebrand disease. Milk allergy and elevated serum liver enzyme levels are not contraindications.
A 36-year-old woman developed numbness in the distribution identified in the picture shown. Which of the following nerves was most likely injured?
A) Lateral antebrachial
B) Medial antebrachial
C) Medial brachial
D) Posterior antebrachial
E) Posterior brachial
The correct response is Option C.
The posterior brachial nerve innervates the dorsal aspect of the upper arm. The lateral antebrachial nerve innervates the radial side of the forearm. The medial antebrachial nerve innervates the ulnar side of the forearm and medial upper arm.
The medial brachial nerve innervates the medial aspect of the upper arm between the medial antebrachial cutaneous (MABC) and intercostobrachial nerves.
The posterior antebrachial nerve innervates the lateral posterior aspect of the forearm.
When comparing the traditional bicipital groove brachioplasty with the posterior-incision approach, which of the following statements is most accurate?
A) Excision-site liposuction should not be used with the posterior incision brachioplasty
B) Injury to the medial antebrachial cutaneous nerve is unlikely with the posterior incision brachioplasty
C) Most patients rate the postoperative scar appearance as “unsatisfactory” with the posterior incision brachioplasty
D) A posterior-incision brachioplasty cannot be easily extended down the lateral chest wall, if needed, to deal with lateral chest laxity
E) Tailoring of skin excess is more complex with the posterior incision approach
The correct response is Option B.
Posterior-incision brachioplasty has a number of advantages over the standard design. The incision runs from the posterior elbow region, straight up the midline posterior surface of the arm, when marked with the arm abducted at 90 degrees and the elbow flexed. The incision is placed in the posterior axillary fold, not the dome of the axilla, extending down the posterior surface of the arm. A simple ellipse of skin is resected, making tailoring of the skin excess straightforward. Preliminary liposuction of the excisional site is helpful, and a skin-only excision may be performed, sparing deeper structures and facilitating closure.The design may be extended down the lateral chest, when needed for patients with skin excess in that region. The medial antebrachial cutaneous nerve (MABC) is unlikely to be injured with this incision design. Concurrent liposuction of the arm with the posterior incision brachioplasty can facilitate shaping and skin resection with predictable results and good outcomes, as published by Nguyen and Rohrich. Elkhatib’s study found an 88.8% patient satisfaction rating with the quality of the resultant incisional scar.
References
A 43-year-old woman comes to the office to discuss a circumferential body lift. Medical history includes massive weight loss following Roux-en-Y gastric bypass surgery 3 years ago. Current medications include a daily multivitamin. The patient has not consistently kept follow-up appointments with her gastric bypass team and reports that she has not rigorously adhered to diet and supplementation recommendations. Which of the following nutrients is most likely to be deficient in this patient?
A) Folate
B) Iron
C) Magnesium
D) Vitamin B6 (pyridoxine)
E) Vitamin E
The correct response is Option B.
Iron deficiency is common after Roux-en-Y gastric bypass and is difficult to correct with only multivitamin supplementation. Folate deficiencies after gastric bypass are usually corrected by multivitamin supplementation. While other B-complex vitamin deficiencies are encountered after gastric bypass, vitamin B6 deficiencies have not been linked to gastric bypass. Magnesium deficiencies are not commonly encountered as a result of gastric bypass. Vitamin E, while a fat soluble vitamin, is not routinely noted to be deficient following gastric bypass, unlike the other fat-soluble vitamins.
A 52-year-old man underwent a single session of cryolipolysis. BMI before the session was 28.5 kg/m2. The session lasted 1 hour and a large applicator was used over the infraumbilical abdominal region. After the procedure, mild edema with cutaneous erythema was noted. Two months after cryolipolysis, the treated area progressively increased in size. The area was painless but firmer and thicker than the surrounding abdominal tissue. These findings are most suggestive of which of the following conditions?
A) Hematoma
B) Lymphocele
C) Paradoxical adipose hyperplasia
D) Seroma
E) Weight gain
The correct response is Option C.
Cryolipolysis is a minimally invasive technique for decreasing localized areas of adiposity using thermal cooling. It was approved for use on the abdomen by the Food and Drug Administration in 2010. Paradoxical adipose hyperplasia (PAH) is a known complication of cryolipolysis and is usually characterized by localized hypertrophy of fat in a treated area. Risk factors identified that increase the development of PAH include male sex, large applicator size, abdominal treatment and previous history of cryolipolysis in the area being treated.
According to Poiseuille’s law, with all other factors being equal, which of the following is the approximate amount of fat extraction per unit time through a 5-mm liposuction cannula compared with a 4-mm cannula?
A) 1.25 times more
B) 1.5 times more
C) 2 times more
D) 2.5 times more
E) 4 times more
The correct response is Option D.
Poiseuille’s law governs the flow of liquids through a tube. Flow is related to the radius of the tube to the fourth power. Doubling the radius of a tube increasing flow by a factor of 16. Thus the ratio can be calculated as (r1 / r2)4.
In this case, the calculated answer is (2.5/2)4 is 2.44, or approximately 2.5 times more flow. Thus, during liposuction, smaller cannulas extract the fat more slowly, allowing for finer work.
In practice, calculation of the actual fat extraction rate also varies with the cannula tip design, length of tubing and homogeneity of the fatty aspirate. Computerized models for flow calculations exist.
A 43-year-old woman presents to the clinic for evaluation and treatment of excess subcutaneous tissue in the lower abdomen following cryolipolysis treatments 6 months ago in this area. The area is nontender, soft, mobile, and not discrete. Which of the following is the most appropriate recommendation for this patient?
A) Liposuction
B) Massage
C) Repeat cryolipolysis
D) Steroid injection
The correct response is Option A.
This patient has paradoxical adipose hyperplasia (PAH) which is a rare side effect of cryolipolysis. This rare complication usually presents several months after the initial therapy, and the incidence is less than 1%. Treatment of larger areas of PAH usually involves waiting 6 to 9 months for soft tissue to soften and then performing liposuction and/or abdominoplasty to remove the affected area.
While massage following cryolipolysis is commonly described to improve efficacy, there are no data to support massage for PAH.
There are no data to suggest injection of steroids has any effect on PAH.
A 52-year-old woman presents to the clinic desiring body contouring surgery. She underwent gastric bypass surgery 2 years ago and has excess skin involving the arms, thighs, breasts, and abdomen. Circumferential body-lift and mastopexy using barbed sutures for dermal closure are planned. Which of the following outcomes is an advantage of using running barbed sutures compared to traditional interrupted suture techniques in this patient?
A) Decreased major postoperative complications
B) Decreased operative time
C) Improved scar aesthestics
D) Improved scar strength
The correct response is Option B.
Barbed sutures are available today from several manufacturers and in several styles. They have gained popularity due to advantages over traditional suture techniques.
Several studies utilizing barbed suture versus traditional closure have demonstrated decreased length of surgery leading to overall decreased operative time and improved surgeon satisfaction. Barbed suture itself is more expensive, but overall cost savings may be noted due to shorter total duration of surgery.
There are no studies demonstrating significant differences in tensile strength of the scar. Several studies have demonstrated scar aesthetics are equivalent. Overall, major complication rates are similar; although studies have suggested higher rates of suture extrusion and minor wound healing complications.
A 27-year-old woman comes to the office for large-volume liposuction of the abdomen, back, hips, and thighs. She has no history of medical issues. Tumescent liposuction using an infiltrate that contains lidocaine is performed. Thirty minutes into the procedure, the patient is noted to have tremors and a seizure. Several minutes later, the anesthesiologist states that the patient has a ventricular arrhythmia. Administration of which of the following agents is most appropriate for this patient?
A) Dantrolene
B) Flumazenil
C) Lipid emulsion
D) Naloxone
E) Steroids
The correct response is Option C.
The patient is experiencing local anesthetic systemic toxicity related to the lidocaine infiltration. Patients experience nervous system effects and can progress to cardiovascular effects. Early findings associated with lidocaine toxicity include perioral numbness, metallic taste, anxiety, muscle twitching, and seizures. Cardiovascular findings can include tachycardia and hypertension that can progress to ventricular arrhythmias and, ultimately, asystole.
Treatment of lidocaine toxicity includes advanced cardiac life support and administration of a bolus of 20% lipid emulsion.
Dantrolene is used for the treatment of malignant hypothermia. Flumazenil is used as an antidote for benzodiazepine overdose. Naloxone, an opioid antagonist, is used to treat an overdose due to opioids. Corticosteroids have been proposed along with supportive therapy for the treatment of fat embolism.
A 48-year-old man presents with a history of 140-lb (63.5-kg) weight loss and moderate upper extremity adiposity with skin excess. Brachioplasty is performed. One week postoperatively, the patient reports numbness of the area in the image shown. Which of the following nerves is most likely affected in this patient?
A) Inferior lateral
B) Lateral antebrachial
C) Medial antebrachial
D) Posterior antebrachial
E) Posterior brachial
The correct response is Option C.
The medial antebrachial cutaneous nerve represents the sensory distribution shown in the illustration of the arm. This includes the skin of the anterior and medial surface of the forearm as far down as the palmar side of the wrist. This nerve also innervates the medial and posterior sides of the elbow area. Due to its anatomical course, the nerve may become easily injured.
The medial antebrachial cutaneous nerve originates from roots C8 and T1, and it branches from the medial cord of the brachial plexus just distal to the medial brachial cutaneous nerve and just proximal to the ulnar nerve. The nerve descends into the arm anterior and medial to the brachial artery. It lies on the ulnar side next to the biceps muscle as it runs distally. The nerve branches into an anterior and posterior branch just proximal and anterior to the medial epicondyle. The nerve provides sensation to the medial forearm and includes an anterior and a posterior branch. The posterior branch provides sensation to the resting surface of the elbow and forearm. The anterior division is expendable for graft material. Injury to this nerve during surgical procedures can lead to sensory loss and painful neuroma formation.
The adjacent sensory distribution includes:
Lateral/anterior: lateral antebrachial cutaneous nerve
Lateral/posterior: posterior antebrachial cutaneous nerve
Distal/anterior: palmar cutaneous branch of ulnar nerve
Distal/posterior: dorsal cutaneous branch of ulnar nerve
The lateral antebrachial cutaneous nerve is incorrect. It originates from C5, C6, and C7 and is the terminal part of the musculocutaneous nerve. It innervates the lateral forearm.
The inferior lateral cutaneous nerve arises from C5 and C6 and branches from the radial nerve to provide sensory and vasomotor innervation to the lower lateral aspect of the arm.
The posterior brachial cutaneous nerve arises from C5, C6, C7, and C8 and branches from the radial nerve to innervate the posterior aspect of the arm.
The posterior antebrachial nerve originates from roots C5, C6, C7, and C8 and branches from the radial nerve just distal to the posterior brachial cutaneous nerve in the axilla. It provides sensation to the posterior cutaneous aspect of the forearm.
A 28-year-old woman with history of lipodystrophy of the abdomen and waist is scheduled for suction-assisted lipectomy under general anesthesia. On the day of surgery, the anesthesiologist is planning intravenous fluid management of the patient and requests more information about the volume infusion plan for the wetting solution. The surgeon anticipates 1.5 L of lipoaspirate. For employment of a superwet technique, which of the following is the appropriate amount of fluid for the patient to receive in subcutaneous tissue infiltration?
A) 0 mL
B) 375 mL
C) 750 mL
D) 1500 mL
E) 3000 mL
The correct response is Option D.
Originally, liposuction was performed without wetting solutions, however, this technique was associated with a reported estimated blood loss of up to 45% of aspirate. Infiltrating wetting solutions with a base of normal saline or Ringer’s lactate with additives (e.g., epinephrine and lidocaine) prior to suctioning improves hemostasis and pain control. The current options for wetting solutions are dry, wet, superwet, and tumescent. The dry technique is rarely used and no wetting solution is infused. The wet technique employs injection of a standard 200 to 300 mL of wetting solution per anatomic area to be treated, irrespective of the anticipated lipoaspirate. The superwet technique is predicated on a 1:1 ratio of 1 mL of solution instilled per 1 mL of aspirate. True tumescent infiltration involves infiltration at a ratio of 2:1 or 3:1 of wetting solution per mL of expected lipoaspirate.
The use of 0 mL of fluid denotes a dry technique, 375 mL is a wet technique, 750 mL does not fall into any category, and 3000 mL is a tumescent technique.
A 28-year-old man presents with concerns of excess fullness of the lower abdomen and flanks. He is not interested in undergoing any surgical intervention. Noninvasive body contouring with cryolipolysis is planned. Which of the following is the most appropriate description of the mechanism of action of this treatment?
A) Adipocyte apoptosis with inflammatory cell infiltration
B) B cell lymphocytes tissue invasion at 3 months
C) Cellular edema and increased Na-K-ATPase activity
D) Cytosolic calcium level depletion
E) Peak cellular inflammation at 7 days
The correct response is Option A.
Cryolipolysis is one of the most recent forms of noninvasive fat reduction to emerge. “The development behind cryolipolysis stems from the clinical observation of cold-induced panniculitis.” In this technique, an applicator is applied to the targeted area and set at a 44 degrees Fahrenheit temperature for a preset period of time. This targets adipocytes while sparing the skin, nerves, vessels, and muscles.
The initial insult of crystallization and cold ischemic injury induced by cryolipolysis is further compounded by ischemia reperfusion injury, causing generation of reactive oxygen species, elevation of cytosolic calcium levels, and activation of apoptotic pathways.
This cold ischemic injury may promote cellular injury in adipose tissue via cellular edema, reduced Na-K-ATPase activity, reduced adenosine triphosphate, elevated lactic acid levels, and mitochondrial free radical release.
Another mechanism proposes that, ultimately, crystallization and cold ischemic injury of the targeted adipocytes induce apoptosis of these cells and a pronounced inflammatory response, resulting in their eventual removal from the treatment site within the following weeks.
Most studies demonstrate an inflammatory response at different stages after cryolipolysis, with inflammatory cell infiltrates peaking at 30 days.
Histologic studies show that within 3 months, macrophages are mostly responsible for clearing the damaged cells and debris.
A 38-year-old woman undergoes abdominoplasty surgery. During the procedure, the surgeon notes significant midline diastasis recti abdominis and opts to repair the defect from the level of the xyphoid process to just above the symphysis pubis. To decrease the pain associated with the procedure, the surgeon decides to administer bupivacaine liposome injectable suspension. For optimal pain control, which of the following planes above the level of the umbilicus is the most appropriate site of injection?
A) At the anterior rectus sheath
B) Between the external abdominal oblique and internal abdominal oblique muscles
C) Between the internal abdominal oblique and transverse abdominal muscles
D) Between the transversalis fascia and preperitoneal fat
E) Between the transverse abdominal muscle and the transversalis fascia
The correct response is Option C.
A recent finding emphasizes the two-wound model after abdominal surgery. The first model is the somatic wound which corresponds to the abdominal wall. The second model is the autonomic wound which corresponds to the peritoneal layer and visceral component.
The intercostal nerves (arising from T6 to T12) and ilioinguinal/iliohypogastric nerves (arising from L1) provide sensation to the abdominal wall. These nerves are easily blocked throughout their course between the abdominal muscles.
After emerging from the paravertebral space, the intercostal nerves are located coursing between the transversus and the internal abdominal oblique muscles. This anatomic plane is called the transversus abdominis plane (TAP). At the anterior superior iliac spine, the ilioinguinal and iliohypogastric nerves, which were previously located in the TAP move to the space between the internal abdominal oblique and external abdominal oblique muscles. These nerves provide sensation to the inguinal region along with the skin around the pubic symphysis.
A 39-year-old woman presents for an abdominoplasty. She has a family history of thrombosis. Her only current medication is an oral contraceptive. BMI is 26 kg/m2. Which of the following factors has the largest impact on this patient’s risk for deep venous thrombosis?
A) Abdominoplasty
B) Age
C) BMI
D) Family history of thrombosis
E) Oral contraceptive use
The correct response is Option D.
It is recommended that plastic surgeons use the 2005 Caprini scale to assess the risk for deep venous thrombosis. On the basis of this scale, the patient’s family history of thrombosis contributes three points to her overall Caprini score.
The patient’s age, BMI, and use of birth control pills each contribute 1 point to her score.
Abdominoplasty would be considered a major surgery since the time for surgery is longer than 45 minutes. As a result, this would contribute two points to the patient’s Caprini score. While many surgeons consider abdominoplasty to carry one of the highest risks for deep venous thrombosis, this conclusion has not been supported by a review of the literature.
A post-bariatric surgery patient with excess medial arm skin is scheduled to undergo posteromedial scar-approach brachioplasty. Which of the following is the most likely advantage of this method of brachioplasty compared with other techniques?
A) Hidden location of the surgical scar
B) High mechanical stress on the surgical incision and scar
C) High risk for surgical scar widening and hypertrophy
D) Long surgical scar length
The correct response is Option A.
The brachioplasty or arm reduction approach for this type of patient would entail making a longitudinal excision of skin and subcutaneous fat running the full length of the arm, from axilla to elbow.
Brachioplasty is a body-contouring procedure often done in bariatric surgery patients who demonstrate laxity and tissue excess of the arms following weight loss.
The brachioplasty approach utilizing the posteromedial incision has been shown to minimize tension on the surgical incision, which leads to better scarring and less visibility of the arm scars.
An otherwise healthy 34-year-old woman who underwent liposuction of the abdomen, flanks, and thighs three days ago is evaluated because of shortness of breath, confusion, and a petechial rash. Temperature is 38.2°C (100.8°F), blood pressure is 110/80 mmHg, heart rate is 100 bpm, respiratory rate is 16/min, and oxygen saturation is 89%. Which of the following is the most likely cause of this patient’s symptoms?
A) Drug reaction
B) Fat embolism
C) Lidocaine toxicity
D) Sepsis
E) Thrombocytopenia
The correct response is Option B.
Fat embolism is a rare complication after liposuction that presents with three classical symptoms: respiratory distress, cerebral dysfunction, and petechial rash. Symptoms generally commence 24 to 72 hours after the liposuction procedure and require urgent evaluation and management.
Lidocaine toxicity may have cerebral and respiratory changes, but a petechial rash is not common. Both a drug reaction and thrombocytopenia may manifest as petechial rashes, but neither is usually associated with significant mental changes and respiratory distress. Sepsis could manifest with the clinical symptoms listed, but with normotension and lack of significant fever, this choice is not as likely.
A 25-year-old woman comes to the office to discuss gluteal fat grafting. BMI is 27.5 kg/m2. She is otherwise healthy. Which of the following surgical techniques will most likely minimize this patient’s risk for a fatal pulmonary fat embolism?
A) Avoid intramuscular injection of fat
B) Centrifuge fat prior to grafting
C) Inject fat only when the cannula is stationary
D) Use a grafting cannula size greater than or equal to 2 mm
E) Use a long cannula to avoid multiple incisions
The correct response is Option A.
Gluteal fat grafting continues to be a commonly requested operation. There is a significantly higher mortality associated with this operation than any other aesthetic operation. The vast majority of these deaths are caused by a fatal pulmonary fat embolism.
The most common causative mechanism is a mechanical tear of a large gluteal vein followed by either intravascular injection of fat or migration of extravascular fat into an injured vein by a pressure gradient. Avoiding intramuscular fat injection greatly reduces the risk for fatal pulmonary embolism.
Surgical technique recommendations for minimizing fatal pulmonary embolism include avoiding injecting into the muscle, using a single-hole cannula greater than 4.1 mm in diameter, avoiding downward angulation of the cannula, and only injecting when the cannula is in motion.
Long injection cannulas that are narrower than 4 mm may bend and inadvertently perforate the muscle. Whether the harvested fat is centrifuged or decanted will not significantly minimize the risk for death.
A 30-year-old Hispanic man reports a gradual increase in size of his lower abdomen after undergoing two rounds of cryolipolysis on that location approximately 8 months ago at another plastic surgeon’s office. He states that the large applicator was used for each treatment. His early recovery after the treatments was otherwise uneventful. He is healthy and reports that his weight has not changed significantly. Physical examination shows a well-demarcated zone of adiposity in the treated area. Which of the following factors is most likely unrelated to the patient’s risk for this problem?
A) Abdomen as the site of treatment
B) Age less than 35 years
C) Hispanic background
D) Male sex
E) Use of a large applicator
The correct response is Option B.
Paradoxical adipose hyperplasia (PAH) is a known complication of cryolipolysis. The incidence has increased in more recent reports, ranging between one per 5000 treatment cycles and one per 500 cycles, both well beyond the manufacturer’s quoted figures. Known risk factors include: use of a large applicator, male sex, Hispanic background, and abdominal location of treatment. Age has not been shown to be a factor in the development of PAH.
The treatment for PAH is power-assisted liposuction once the affected area has softened, which normally occurs 6 to 9 months after the initial cryolipolysis procedure.
A 45-year-old woman is undergoing abdominal and flank liposuction. When the superwet liposuction technique is used, estimated blood loss is closest to which of the following percentages of the lipoaspirate?
A) 0.1%
B) 1%
C) 15%
D) 30%
E) 50%
The correct response is Option B.
The best estimate of blood loss during either superwet or tumescent technique liposuction is 1% of the lipoaspirate. There may, however, be differences in true blood loss based on interstitial extravasation. Techniques that employ smaller ratios of tumescent solution infusion generally lead to higher levels of blood loss, as high as 20 to 40% of the lipoaspirate.
A 28-year-old woman with history of lipodystrophy of the abdomen and waist plans to undergo suction-assisted lipectomy while receiving general anesthesia. The surgeon anticipates 1.5 L of lipoaspirate. With a superwet technique, how much fluid is the patient most likely to receive in the form of subcutaneous tissue infiltration?
A) 0 mL
B) 375 mL
C) 750 mL
D) 1500 mL
E) 3000 mL
The correct response is Option D.
Originally, liposuction was performed without wetting solutions, but this technique was associated with reported estimated blood loss of up to 45% of aspirate. Infiltrating wetting solutions with a base of normal saline or Ringer’s lactate with additives epinephrine and lidocaine prior to suctioning improves hemostasis and pain control. The current options for wetting solutions are dry, wet, superwet, and tumescent. The dry technique is rarely used and no wetting solution is infused. The wet technique employs injecting a standard 200 to 300 mL per anatomic area to be treated, irrespective of the anticipated lipoaspirate. The superwet technique is predicated on a 1:1 ratio of instilling 1 mL of solution per 1 mL of aspirate. True tumescent infiltration involves infiltration at a ratio of 2 to 3:1 of wetting solution per mL of expected lipoaspirate.
0 mL is a dry technique, 375 mL is a wet technique, 750 mL does not fall into any category, and 3000 mL is tumescent technique.
Which of the following procedures has the greatest risk of potential venothromboembolism (VTE)?
A) Abdominoplasty
B) Bilateral reduction mammaplasty
C) Implant-based calf augmentation
D) Liposuction of the trunk
The correct response is Option A.
There is level II evidence provided by Winocour et al in 2017 by querying the Cosmetassure database of more than 129,000 patients that body procedures such as lower body lift and abdominoplasty have higher risk than breast, liposuction, or facial procedures. More specific level II evidence about abdominoplasty and venothromboembolism (VTE) was published in 2018 Keyes et al. after querying the Internet Based Quality Assurance Program database, that BMI greater than 25 kg/m2 and age greater than 40 were independent predictors of VTE risk. Most of the patients in this study who had VTE had pre-operative Caprini scores of 2 to 8, which would not typically make these patients recipients of chemoprophylaxis against VTE.
Although operating in the area of the calf muscles seems like a good source of potential VTE, there is no reference to calf implants in these large database studies, and a PubMed search of VTE and calf implants returns no literature.
For a generalized summary of risk stratification, consult the Pannucci et al. article.
A patient who had massive weight loss comes to the office to discuss reconstruction. The surgeon determines that the patient would benefit from a lower body lift. Advancement of the flaps in this procedure will be best achieved by undermining which of the following zones of adherence?
A) Distal posterior thigh
B) Gluteal crease
C) Inferolateral iliotibial tract
D) Lateral gluteal depression
E) Mid medial thigh
The correct response is Option D.
Continuous or discontinuous release of the lateral gluteal depression would be the most effective in allowing the advancement of the flaps in a lower body lift. Though the gluteal crease is in proximity of the flaps, release here would undesirably blunt this crease. The other choices are not in proximity and their release would have little effect on advancing the flaps.
To avoid damage to the medial antebrachial cutaneous nerve during brachioplasty, which of the following veins is most important to mark?
A) Axillary vein
B) Basilic vein
C) Brachial vein
D) Cephalic vein
E) Innominate vein
The correct response is Option B.
Care is used to avoid damage to the medial antebrachial cutaneous nerve of the forearm in the distal third of the medial arm. The nerve divides into anterior and posterior branches around the basilica vein. The other veins, axillary, cephalic, and brachial are incorrect.
A 35-year-old woman who is morbidly obese comes to the plastic surgery clinic to discuss body contouring. She is counseled that losing weight before undergoing contouring may be beneficial. Which of the following methods of weight loss is most likely to increase this patient’s risk for surgical complications during body contouring?
A) Exercise
B) Gastric band/sleeve
C) Gastric bypass
D) Liposuction
E) Low-carbohydrate diet
The correct response is Option C.
Multiple studies have demonstrated that results from body contouring after massive weight loss depend somewhat on the method of weight loss. Weight loss via gastric bypass has been shown to be associated with higher rates of surgical complications following body contouring than other weight loss methods.
A 45-year-old man is evaluated for a body lift after undergoing bariatric surgery and subsequent 100-lb weight loss. Which of the following characteristics would make this patient an inappropriate candidate?
A) BMI of 30 kg/m2
B) History of deep venous thromboembolism
C) Protein intake of 25 g daily
D) Transverse abdominal scar
E) Type 2 diabetes
The correct response is Option C.
Achieving satisfactory outcomes while minimizing morbidity requires careful assessment of the patient’s comorbidities, nutritional deficiencies, and psychological issues. A history of venous thromboembolism is not a contraindication for body contouring procedures but requires evaluation of the patient by a hematologist and postoperative thromboembolism prophylaxis. Type 2 diabetes is not a contraindication for a circumferential body lift. BMI is a predictor of complications following body contouring procedures. Higher BMI (BMI >35) is associated with increased complication rates.
Nutritional status in the postbariatric patient is important to achieving successful outcomes for the body lift patient. Deficiencies in calcium, vitamin B12, folate and thiamine should be corrected prior to surgery. Protein deficiencies have been shown to significantly lower healing rates among massive weight loss patients. Studies have indicated that a minimum of 60 to 100 g daily of protein is necessary to prevent malnutrition and avoid delayed wound healing in such patients. Daily protein intake of 25 g or less would produce severe malnutrition and be a contraindication for surgery.
An otherwise healthy 29-year-old woman presents for improvement of the appearance of her buttocks with added volume and projection throughout. Liposuction of the abdomen, flanks, and back is performed. Gluteal augmentation with autologous fat grafting is planned. The fat has been prepared and aliquoted into 60 mL syringes with a 5-mm-caliber blunt injection cannula attached. In order to both maximize the aesthetic results and decrease the risk for fat macroembolism, the injection cannula should be directed within which of the following tissue planes?
A) Intramuscular only
B) Subcutaneous inferiorly and superficial muscular superiorly
C) Subcutaneous medially and superficial muscular laterally
D) Subcutaneous only
The correct response is Option D.
Based on the Aesthetic Surgery Education and Research Foundation (ASERF) task force recommendations and knowledge of gluteal anatomy, the risk of fat macroembolism and subsequent mortality with gluteal fat grafting is greatest when fat is injected intramuscularly, cannulas smaller than 4 mm in diameter are utilized, and/or the cannula is directed in a downward (deeper) trajectory. Conceptually, placement of fat grafts into the subcutaneous plane only will likely avoid cannulation of or injury to the gluteal vein(s) and the risk of fatal pulmonary fat macroembolus.
A 58-year-old woman is evaluated for seroma six weeks after undergoing a lower body lift following massive weight loss. The surgery was uneventful, and the drain had been removed. Repeated aspirations of the seroma were done without success. The surgeon is considering injection of a sclerosant agent into the seroma space. Which of the following agents is most likely to be used?
A) Doxorubicin
B) Doxycycline
C) Erythromycin
D) Gentamycin
The correct response is Option B.
Seroma presents as a common postoperative management problem in plastic surgery, particularly in body contouring for massive weight loss. The combination of potential injury to a rich lymphatic supply, possible excision of lymphoid tissue, and extensive subcutaneous dissection in adjacent areas, combined with shear forces and motion are the substrates to seroma formation. The most widely used treatment strategies for effusions include percutaneous aspiration, drainage, and injection of sclerosant agents through chest tubes. Doxycycline and bleomycin are the most common sclerosant agents used.
An otherwise healthy 32-year-old woman is considering liposuction. Assuming that the patient maintains her current weight, which of the following most accurately describes the anticipated changes in her body fat distribution after surgery?
A) Long-term reduction in the abdomen but eventual reaccumulation in the hips
B) Long-term reduction in the hips but eventual reaccumulation in the abdomen
C) Long-term reduction in treated areas but compensatory increase in fat in untreated areas
D) Long-term reduction in treated areas without reaccumulation in treated or untreated areas of the body
E) Short-term reduction in treated areas but eventual long-term fat reaccumulation in these areas
The correct response is Option D.
Available recent Level III evidence using prospectively collected standardized photographic measurements in patients who have undergone liposuction and/or abdominoplasty versus retrospective controls demonstrated that removal of excess fat through these methods provided long-term reduction in treated areas without fat reaccumulation in either treated or untreated areas of the body. This evidence contradicts the commonly held notion (mostly by the lay public) that removal of fat in one location leads to “return” of fat in another.
Short-term reductions of fat with reaccumulation in treated and/or untreated areas can occur if the patient does not remain calorically neutral after surgery. However, in this clinical scenario, it is mentioned that this patient has had no postoperative increase in caloric intake.
A 32-year-old woman is evaluated for trunk contouring 12 months after undergoing laparoscopic gastric bypass surgery. Hypertension and sleep apnea have resolved. Current BMI is 32.7 kg/m2. She reports an 80-lb (36.2-kg) weight loss and is still actively losing weight. Which of the following is the most appropriate next step in management?
A) Complete blood cell count
B) CT scan of the abdomen
C) Panniculectomy
D) Re-evaluation in 6 months
E) Referral to psychiatry
The correct response is Option D.
In patients who have undergone gastric bypass surgery, consensus recommendations are to wait to proceed with body contouring surgery until the patient is at least 1 year from surgery. Additionally, recommendations are to wait until the patient has had a stable weight for at least 3 months and some authors advocate 6 months of weight stability. This is due to the fact that additional weight loss after surgery may result in recurrence of skin laxity. Stability of the long-term result is best achieved when there is stability of the underlying weight. Furthermore, risk of surgery increases with increasing BMI, thus waiting for the patient to achieve their lowest BMI prior to performing surgery will limit weight-associated risks. It is for these reasons that a return visit for reassessment in 6 months is the best choice as opposed to proceeding to panniculectomy at this time.
A CT scan is indicated in those patients where a physical examination is unable to rule out an abdominal wall hernia. In an otherwise asymptomatic patient from a hernia standpoint, reassessment of the physical examination once the patient has achieved a stable weight is the time to determine if there is an abdominal wall hernia that would be addressed at the time of body contouring surgery. At this point in time, the patient may have lost enough weight to adequately assess the abdominal wall for a hernia, and thus make a CT scan unnecessary.
Most post-bariatric patients will be obtaining laboratory assessments from their bariatric surgeon to assess for nutritional deficiencies and will be on supplements as indicated. After undergoing bariatric surgery, many patients have iron deficiency anemia. A complete blood count may be indicated for those who have symptoms or signs of anemia, or in whom a significant blood loss is anticipated. In relation to the body contouring surgery, this test is best undertaken once the plan to proceed with surgery is made. Again, this would occur once a stable weight has been achieved.
Many patients with weight control issues suffer from mental health pathology. A referral to a psychiatrist would be indicated in any patient who has a history of mental health issues or demonstrates signs or symptoms of psychopathology prior to embarking on post bariatric body contouring. As this patient has no medical issues noted, the routine referral to a mental health provider is not indicated.
Which of the following measures reduces the risk for the most common complication in abdominoplasty?
A) Administration of preoperative intravenous antibiotics within 1 hour of incision
B) Attention to offloading pressure points and keeping upper extremities in neutral position
C) Discontinuation of NSAIDs and herbal supplements 4 weeks before surgery
D) Use of pneumatic compression devices before the induction of general anesthesia
E) Use of progressive tension sutures and drain placement
The correct response is Option E.
Seroma is the most common complication following abdominoplasty. Progressive tension sutures and/or use of drains have been shown to be effective in preventing this complication.
Use of antibiotics is intended to prevent infection. Discontinuation of NSAIDs, fish oil, and herbal supplements is intended to decrease the incidence of hematoma.
Offloading pressure points and extremities in neutral position is to decrease the incidence of neuropathies postoperatively.
Pneumatic compression devices and subcutaneous heparin and enoxaparin are intended to decrease the incidence of venous thromboembolism.
A 35-year-old woman comes to the office to discuss improving the contour of her thighs. History includes gastric bypass surgery two years ago, followed by a stable 150-lb (68-kg) weight loss. Along with moderate horizontal excess skin, she has significant vertical excess skin, and a full-length vertical thighplasty is considered. This patient is at greatest risk for which of the following complications?
A) Hematoma
B) Infection
C) Labial spreading
D) Prolonged edema
E) Seroma
The correct response is Option D.
Each of the complications listed in this question has a significant occurrence with thighplasty in the massive-weight-loss population, but prolonged edema has been shown to be a particular risk factor in patients getting a full-length vertical component in their thighplasty, presumably due to circumferential compression of the low pressure lymphatic system. Labial spreading is possible but not likely.
A healthy 29-year-old woman undergoes suction-assisted lipectomy with a tumescent solution for thigh lipodystrophy. A maximal dose of lidocaine 55 mg/kg is planned through the tumescent solution, and aspiration is planned through a 4-mm blunt-tipped cannula. Which of the following best approximates the expected percentage of local anesthetic in the aspirated material?
A) 20%
B) 50%
C) 70%
D) 90%
The correct response is Option A.
While there is evidence that doses of up to 55 mg/kg can be safely used in liposuction, the safe dose is likely dependent on the vascularity of the tissue injected rather than aspiration of the local anesthetic during the procedure. Studies have shown that between approximately 10 and 30% of local anesthetic is present in the aspirate, and one study showed that a mean of 9.8% of wetting solution was removed.
The knowledge that the majority of tumescent solution remains in vivo is important because lidocaine toxicity is a risk after tumescent liposuction.
A 48-year-old man who underwent laparoscopic gastric bypass surgery 2 years ago is evaluated for a belt lipectomy after a massive weight loss of 150 lb (68 kg). He has maintained a stable weight for over 6 months. Current BMI is 30 kg/m2. Which of the following factors most increases the risk for hematoma in this patient?
A) Age
B) Gender
C) Location of incision
D) Postoperative BMI
The correct response is Option B.
Male gender is an increased risk factor for hematoma and seroma in body contouring patients, independent of hypertension. Age, incision site, and postoperative BMI have not been shown to increase the risk for hematoma.
A 35-year-old woman, gravida 3, para 3, is interested in a “mommy makeover”, with liposuction of the flanks, extended tummy tuck, brachioplasty, and augmentation mammaplasty. In this combination of surgeries, which of the following percentages best represents the cumulative risk in the general population for postoperative complications requiring reoperation or hospitalization?
A) 3%
B) 12%
C) 25%
D) 35%
E) 50%
The correct response is Option B.
Abdominoplasty is known to have a higher complication rate than many common aesthetic procedures. A recent study by Grotting and associates examining complication rates in more than 25,000 abdominoplasties in a multi-surgeon database confirmed that the risk for a complication requiring hospitalization or reoperation increases significantly when abdominoplasty was combined with other surgeries.
In particular, abdominoplasty alone had a complication rate of 3.1%.
Abdominoplasty combined with liposuction – 3.8%
Abdominoplasty combined with a breast procedure – 4.3%
Abdominoplasty combined with a breast procedure and liposuction – 4.6%
Abdominoplasty combined with liposuction and a body contouring procedure – 10.4%
Abdominoplasty combined with liposuction, a breast procedure, and a body procedure – 12.0%
In this study, body procedures included brachioplasty, buttock lift, calf implant, labiaplasty, lower body lift, thigh lift, and upper body lifts.
Hematoma, infection, and suspected or confirmed venous thromboembolism represented 31.5%, 27.2%, and 20.2% of overall abdominoplasty complications in this study.
A second study, by the same group, looking at 129,000 cosmetic surgery patients as a group also confirmed an increased risk for major surgical site infections in cosmetic patients undergoing multiple simultaneous procedures.
Thus, caution is advised when considering multiple procedures concurrently in a higher risk patient.
Which of the following is the most likely result of performing liposuction in conjunction with brachioplasty?
A) Facilitated tissue dissection
B) Lymphedema
C) Skin necrosis
D) Upper arm paresthesia
E) Wound dehiscence
The correct response is Option A.
Liposuction is often used in conjunction with excisional brachioplasty to facilitate dissection of the soft tissue, improve contour, and decrease the risks for nerve injury and lymphedema. There are many different techniques posed in the literature. Liposuction of the planned tissues of excision can ease the dissection planes. It can also be performed in the posterior upper arm to improve contour of the remaining tissues. Nerves and lymphatics are more protected by using liposuction instead of excision to debulk the arm. The use of liposuction does not increase the incidence of skin necrosis or wound dehiscence.
Which of the following is the most common complication after cryolipolysis?
A) Hematoma
B) Paradoxical adipose hyperplasia
C) Seroma
D) Surface contour irregularities
E) Transient hypoesthesia
The correct response is Option E.
Cryolipolysis is a noninvasive technique to preferentially destroy adipose cells through controlled thermal reduction. Exposure of adipose cells to below normal temperatures results in apoptosis-mediated cell death. Adipose cells are more susceptible to thermal reduction as compared with adjacent tissue. The subsequent inflammatory response results in the removal of damaged adipose cells within 3 months. The most common complication following cryolipolysis is hypoesthesia or decreased sensation of the treated areas, which resolves within 6 months. Other complications, which are less common, include paradoxical adipose hyperplasia, surface contour irregularities, and chronic pain. No hematomas or seromas have been reported in the literature.
A 28-year-old woman comes to the office for a consultation on liposuction of the abdomen. She has already had consultations with several other physicians and is unsure whether to undergo suction-assisted liposuction (SAL) or ultrasound-assisted liposuction (UAL). Which of the following is the most significant advantage of choosing UAL over SAL?
A) Better aesthetic outcome
B) Better skin tightening
C) Greater patient satisfaction
D) Less surgeon fatigue
E) Lower complication rates
The correct response is Option D.
The main advantage of ultrasound-assisted liposuction over suction-assisted liposuction is less surgeon fatigue.
In traditional or suction-assisted liposuction, the fat is removed by the repetitive arm movements breaking up the fat. The suction then aspirates the loosened fat. In ultrasound-assisted liposuction, ultrasound energy breaks the fat apart and emulsifies it, thus allowing it to be removed by the suction cannula. The main advantage of this is to decrease surgeon fatigue from the repetitive arm movements and also to help break apart the fat in fibrous areas or areas of scar from prior procedures.
Peer-reviewed studies have not shown any consistent evidence-based benefits for the use of ultrasound-assisted liposuction over suction-assisted liposuction. The aesthetic outcomes, patient satisfaction, and rates of long-term complications appear to be more related to technique and not technology. As a result, suction-assisted liposuction continues to remain the predominant technique of liposuction due to its relatively low cost and the rapid rate at which new technologies are introduced with little objective evidence supporting any additional benefit.
A 39-year-old woman comes to the office for a consultation regarding abdominoplasty. Three years ago, she underwent gastric sleeve bariatric surgery, which was followed by a 100-lb (43-kg) weight loss. Weight has been stable for 1 year. Past medical history includes mitral valve prolapse, sleep apnea, and exercise-induced asthma. The patient is gravida 5, para 2, with 3 miscarriages. Her mother had deep vein thrombosis at 70 years of age while on a 5-hour flight. BMI is 31 kg/m2. Physical examination shows an overhanging panniculus with intertrigo. An evaluation by which of the following is the most appropriate next step?
A) Cardiologist
B) Dermatologist
C) Hematologist
D) Nutritionist
E) Sleep specialist
The correct response is Option C.
This patient presents with multiple risk factors for deep vein thrombosis (DVT). According to the 2005 Caprini Tool for DVT Risk Assessment, this patient has a minimum of 7 points (3 points for family history of thrombosis, 1 point multiple miscarriages (>3 miscarriages), 1 point for BMI > 25, and 2 points for Major Surgery > 45 minutes). With both a family history of thrombosis and multiple miscarriages, there is a significant likelihood that the patient has a genetic thrombophilia. A hematologist will be able to diagnose and quantify the significance of a genetic thrombophilia. A genetic thrombophilia such as Positive factor V Leiden gene mutation, if present, would add an additional 3 points of risk for DVT and pulmonary embolus, bringing the total risk score from 7 to 10. If abdominoplasty were performed, chemoprophylaxis would be highly recommended with these risk factors.
The mechanism of multiple miscarriages in women with thrombophilia is clotting of the placenta and subsequent fetal loss. These women are given anticoagulation chemoprophylaxis during pregnancy to help prevent placental thrombosis.
The most common inherited thrombophilia is factor V Leiden, which is present in 3 to 7% of the Caucasian population. Multiple inherited thrombophilia conditions can be present in the same individual.
Consultations with a sleep apnea specialist, cardiologist, dermatologist, and nutritionist are all reasonable considerations; however, the evaluation for genetic thrombophilia is most crucial to this patient’s evaluation for abdominoplasty.
A 32-year-old woman is interested in post-pregnancy body contouring. BMI is 34 kg/m2. When combined with abdominoplasty, liposuction of which of the following areas has an increased risk for wound healing complications?
A) Flank
B) Lateral hip
C) Lateral thigh
D) Mons pubis
E) Supraumbilical abdomen
The correct response is Option E.
Traditionally, the supraumbilical abdomen has been considered the area where liposuction might further disrupt blood supply already interrupted by the abdominoplasty undermining. Techniques to minimize undermining and preserve blood supply to allow more aggressive liposuction in this area have been reported and are in use. The mons pubis, lateral hip, flank, and lateral thigh blood supplies are less affected by abdominoplasty, and therefore, these areas have traditionally been less prone to complications when liposuction is performed in them at the time of abdominoplasty.
A 43-year-old woman comes to the office for consultation regarding abdominoplasty. She says she is concerned about postoperative hypoesthesia of the abdominal wall. Which of the following areas is most likely to have the greatest decrease in sensation after a traditional abdominoplasty in this patient?
A) Epigastric
B) Infraumbilical
C) Lateral abdominal
D) Mons pubis
E) Subxiphoid
The correct response is Option B.
The innervation to the anterior abdominal wall comes from the anterior cutaneous branches of the 6th to 12th intercostal nerves. The anterior cutaneous nerves perforate the anterior rectus sheath and are severed during the undermining of the abdominal flap during abdominoplasty. The hypogastric or infraumbilical region becomes the distal-most point for sensory innervation from the surrounding intact lateral cutaneous branches of the intercostal nerves that innervate the lateral anterior abdominal wall. The transverse incision from the abdominoplasty limits innervation from the pubic and thigh regions. The mons pubis should not demonstrate much change in sensation as it lies inferior to the surgical scar.
Patients undergoing abdominoplasty should be made aware of the likely decrease in sensation of this area, including superficial touch, superficial pain, pressure, vibration, and temperature.
A 48-year-old woman with a history of a 160-lb (73-kg) weight loss after gastric bypass surgery comes to the office because she seeks a trimmer torso. Current BMI is 29 kg/m2. Physical examination shows excessive skin on the horizontal and vertical dimensions of the abdomen. Which of the following procedures is most likely to result in aesthetic correction of the deformity?
A) Circumferential dermolipectomy
B) Corset abdominoplasty
C) Externally applied laser lipolysis
D) Liposuction of the anterior abdomen
E) Revision of the gastric bypass
The correct response is Option B.
The increasing popularity of bariatric surgical procedures for the management of obesity has generated a plethora of plastic surgical techniques to deal with the sequelae of massive weight loss. A thorough analysis of the anatomical result of weight loss is key in determining the ideal procedure for each individual’s situation and goals. While liposuction might be helpful as an adjunct to surgical excision, it does not usually produce measurable skin tightening in this group of patients. Skin resection options have been devised based on the skin laxity pattern. When significant horizontal and vertical skin excess is present, a corset trunkplasty, devised by A.P. Moya, is the most likely of the choices to result in a trimmer abdomen shape. This option addresses the upper abdominal skin laxity that is not routinely addressed with traditional abdominoplasty. Circumferential dermolipectomy, also known as belt lipectomy, creates a vertical tightening but not a horizontal tightening of loose skin. Laser lipolysis applied externally is not indicated for the management of excessive skin laxity. This patient has achieved an acceptable result (BMI of 29) of bariatric surgery and therefore no revision of the bypass operation is indicated.
A 48-year-old man is evaluated for a panniculectomy for symptomatic panniculitis 18 months status post Roux-en-Y gastric bypass. The patient has lost 150 lb (68 kg), and BMI is 28 kg/m2. He reports taking a multivitamin every day and exercising for 30 minutes three times a week. Physical examination shows no abnormalities. Preoperative nutritional evaluation will most likely show a deficiency in which of the following micronutrients?
A) Iron
B) Vitamin A
C) Vitamin B1 (thiamine)
D) Vitamin B12 (cobalamin)
E) Vitamin D
The correct response is Option A.
Because of the restrictive and malabsorptive components of the procedure, iron deficiency anemia is very common in post-bariatric patients. Iron deficiency occurs in 30 to 50% of post-bariatric patients despite a recommended daily multivitamin.
Roux-en-Y gastric bypass promotes weight loss through both a restrictive component and a malabsorptive component. This has implications for micronutrient absorption, because pancreatic release of enzymes is no longer synced with gastric emptying, and factors involved in the processing and absorption of micronutrients are decreased. Micronutrient deficiencies are common after bariatric surgery, and while many are asymptomatic, they can have effects on wound healing after surgery.
Vitamin B12 deficiencies are most common at least 12 months after surgery and range from 3.6 to 37%, but they depend on chronicity, degree of supplementation, and type of bypass. Brolin, et al, in 2002, compared patients with a distal Roux-en-Y gastric bypass to those with short Roux limbs (150 cm and 50 to 75 cm). Vitamin B12 deficiency was most common in patients who underwent Roux-en-Y gastric bypass, and B12 deficiency was most common after surgery with short limbs (50 to 75 cm). Vitamin B6 (pyridoxine) deficiency is approximately 17.6%. Vitamin B1, (thiamine), deficiency is estimated at 18.3% of post-bariatric patients. Most B complex deficiencies are asymptomatic. Vitamin B12 (riboflavin) deficiency is estimated to be 13.6% one year after bariatric surgery.
Because of the malabsorptive component of Roux-en-Y gastric bypass, fat-soluble vitamin deficiencies can also occur in the post-bariatric patient. Vitamin A deficiency can be progressive, and deficiency is estimated to be 11% one year after surgery and 69% four years after surgery. Vitamin E deficiency is relatively uncommon in post-bariatric patients who are taking supplementation.
A 36-year-old woman with a BMI of 35 kg/m2 undergoes liposuction of the anterior trunk, posterior trunk, and circumferential thighs. Which of the following is the minimum volume of lipoaspirate that can be classified as “large volume” liposuction?
A) 1000 mL
B) 2500 mL
C) 5000 mL
D) 7500 mL
The correct response is Option C.
Lipoaspirate volumes over 5000 mL are what are widely considered to define “large volume” liposuction. This distinction has relevance as it relates to postoperative care. Patients undergoing “large volume” liposuction are often considered for overnight observation as an inpatient admission. The other volumes (1000 mL, 2500 mL, and 7500 mL) are not the cutoffs for consideration as “large volume” liposuction.
A 28-year-old woman suffered a wound dehiscence after an abdominoplasty. History includes a 70-lb (32-kg) weight loss over the past 5 years through diet and exercise. She is angry and wants to know why the separation happened. Which of the following is the most likely contributor to the development of this complication?
A) Central rectus plication
B) Discontinuous release of tissue over the costal margins
C) Extensive undermining over the hips
D) Liposuction of the bilateral mid flanks
E) Liposuction of the central supraumbilical flap
The correct response is Option E.
Liposuction of the central supraumbilical flap may further impair blood supply to the area farthest from the remaining blood supply after undermining and is the most likely of the choices to cause wound healing complications. Extensive undermining over the hips is usually well tolerated and a component of most abdominoplasties. Central rectus plication, if too tight, may contribute to respiratory difficulty or umbilical loss due to constricted blood supply, but it is unlikely to directly relate to poor healing of the midline incisional skin and fat. Liposuction of the bilateral mid flanks (in contrast to the central supraumbilical flap) is usually well tolerated as it allows preservation of the blood supply traveling from the costal region into the flap. While wide undermining over the costal margins may promote poor wound healing of the advanced tissue at the superior aspect of the incision, tunneling or discontinuous release aimed at perforator preservation is a described technique to increase the ability to contour the upper abdomen without concomitant significant increase in wound healing complications.
A 42-year-old woman comes to the clinic because of numbness of the right arm that extends from the mid arm to the medial aspect of the forearm to the wrist 5 weeks after undergoing bilateral brachioplasty. Which of the following operative techniques is most likely to decrease the risk for this numbness while adequately correcting the deformity?
A) Dissecting adjacent to the muscle fascia throughout the length of the arm
B) Dissecting deep to the muscle fascia throughout the length of the arm
C) Leaving a 1-cm cuff of fat overlying the deep fascia throughout the length of the arm
D) Performing a skin-only resection
The correct response is Option C.
The medial antebrachial cutaneous (MABC) nerve arises from the medial cord of the brachial plexus and innervates the medial arm and forearm. Distal to the axilla, the MABC nerve travels with the basilic vein. Anatomic studies have shown that the nerve penetrates the deep fascia approximately 14 cm proximal to the medial epicondyle relatively consistently. It is vulnerable during brachioplasty because of this position. The recommended technique to protect the medial antebrachial cutaneous (MABC) nerve is to leave a 1-cm cuff of fat overlying the deep fascia. A smaller cuff is inadequate to protect the nerve.
In cases where the brachioplasty dissection must extend distal to the elbow, one can minimize injury to the nerve by maintaining a dissection plane superficial to the deep brachial fascia and transitioning to the subcutaneous plane below the elbow.
A skin-only resection is unlikely to adequately correct the defect. Dissecting adjacent to, or deep to, the subcutaneous fascia places the nerve at risk because of the depth of the dissection.
A healthy 40-year-old woman is scheduled for bilateral brachioplasty along with liposuction of the upper arms. Which of the following is the most common unfavorable outcome of this combined procedure?
A) Hematoma
B) Hypertrophic scar
C) Infection
D) Sensory nerve injury
E) Wound dehiscence
The correct response is Option B.
Adverse scarring is a common complication after brachioplasty and can warrant surgical revision in some cases. Liposuction of the arm with concomitant brachioplasty is a well-described and safe procedure. Along with seromas, recent studies show that hypertrophic scarring is the most common adverse outcome after this combined procedure. Other adverse outcomes such as hematoma, infection, and wound dehiscence are less frequently encountered. Sensory nerve injury, especially the medial antebrachial nerve, is possible, although it is much less likely than the incidence of hypertrophic scarring.
A 35-year-old woman undergoes suction-assisted lipectomy of the bilateral arms using a tumescent technique. A total of 500 mL of aspirate is recovered. She is discharged home the same day, and returns to the emergency department 8 hours after discharge. Lidocaine toxicity is suspected. Which of the following symptoms is most likely in this patient?
A) Anisocoria
B) Petechial rash of the neck and axillae
C) Supraventricular tachycardia
D) Tachypnea
E) Tinnitus
The correct response is Option E.
Although safe doses of lidocaine in tumescent solution can reach 35 mg/kg, lidocaine toxicity is still a risk. Peak plasma levels of lidocaine, when injected into fatty tissue, occur 10 to 14 hours after infiltration.
Lidocaine toxicity symptoms include neurologic or cardiac toxicity. In the early stages, the complications are primarily neurologic, and can include slurred speech, restlessness, tinnitus, and a metallic taste, as well as numbness of the mouth. As the concentrations increase, the neurologic concentrations become more severe, and can progress to muscle twitching, seizures, and cardiac arrest. Treatment of lidocaine toxicity is supportive.
A petechial rash of the neck and axillae is a typical sign of fat embolism, and tachypnea is a typical sign of a pulmonary embolism. Anisocoria can be a benign finding, although if it is a new finding, it is suggestive of Horner syndrome or a brain aneurysm.
Supraventricular tachycardia (SVT) refers to tachycardia that occurs above or at the atrioventricular node. Paroxysmal SVT, atrial fibrillation, and Wolff-Parkinson-White syndrome are the most common forms of SVT. SVT can cause syncope and long-term cardiac damage.
An overweight 36-year-old woman who underwent full abdominoplasty by another surgeon 6 months ago is referred to the office from the emergency department because of persistent pain around the right lower quadrant of the abdomen with concomitant paresthesia to the lateral thigh. The patient reports her postoperative course was unremarkable. Abdominal CT scan from the emergency department shows postsurgical changes and an 8 x 1-cm linear fluid collection subjacent to the incision. Which of the following is the most appropriate next step in management?
A) Administer oral gabapentin
B) Apply compression garment
C) Inject a local anesthetic
D) Massage the scar
E) Surgically explore the wound
The correct response is Option C.
In the absence of other postoperative findings, damage to or entrapment of the lateral femoral cutaneous nerve (LFCN) is the most likely cause of this patient’s symptoms. The LFCN exits the abdomen near the anterior superior iliac spine and is the most commonly injured nerve during abdominoplasty (incidence of 1.36%).
If a nerve injury is suspected, the diagnosis can be confirmed by injection of local anesthetic just proximal to the location of the pain or Tinel sign. Conservative treatment includes scar massage and physical therapy aimed at desensitization techniques. These nonoperative treatments can be combined with an oral anticonvulsant such as gabapentin for pain management in the short term. More severe or debilitating symptoms may warrant earlier surgical intervention. However, a local anesthetic nerve block is diagnostic and is indicated prior to either conservative or surgical treatment.
A compression garment would be neither therapeutic nor diagnostic for this patient.
A 40-year-old woman comes to the office for body contouring following a 150-lb (68-kg) weight loss after undergoing laparoscopic gastric banding surgery. Medical history includes deep venous thrombosis 7 years ago while taking progestin for oral contraception. Family history includes two first-degree relatives who sustained a pulmonary embolism. Laboratory studies show the patient has a factor V Leiden coagulation disorder. Which of the following is the most likely cause of this disorder in this patient?
A) Increased levels of coagulation factor V
B) Increased resistance to activated protein C
C) Persistent antibodies to coagulation factor V
D) Protein C deficiency
E) Protein S deficiency
The correct response is Option B.
Factor V Leiden is the most prevalent hypercoagulation disorder. It is the most common genetic risk factor for venous thromboembolism.
Activated protein C, together with its co-factor protein S, inhibits the coagulation cascade by inactivating factor V and factor VIIIa. Activated protein C cleaves factor V in three sites; a mutation in the first site is known as factor V Leiden. In carriers of factor V Leiden, factor Va is inactivated approximately 10 times slower than normal.
Protein C and S deficiencies are described coagulation disorders. Lower levels of these proteins also inhibit the coagulation cascade and may be associated with warfarin-related skin necrosis and purpura fulminans in the neonatal period.
The most common cause of acquired coagulation disorders is antiphospholipid syndrome, an autoimmune disorder caused by antibodies to phospholipids. These antibodies include anticardiolipin, lupus anticoagulant and anti-beta-2-glycoprotein I.
Increased levels of coagulation factors VIII, IX and XI are associated with increased risk of thromboembolism.
For women undergoing abdominoplasty after massive weight loss, which of the following is the best position of the navel?
A) Along the line drawn between the iliac crests
B) At the horizontal level of the tenth ribs
C) Between the first and second tendinous inscriptions
D) In the midline 10 cm above the vulvar commissure
E) One-third of the distance from the xiphoid to the pubis
The correct response is Option A.
As a result of the rapid increase in the number of bariatric surgical procedures performed each year, the frequency of body contouring procedures has risen concomitantly over the past decade. Among the most popular of these is abdominoplasty for resection of redundant skin on the torso. When designing the outline of skin to be resected, among the preeminent concerns is maximizing the aesthetic result of the procedure. Removal of the redundant panniculus may involve a low transverse incision only or a more extensive resection such as the fleur-de-lis or corset pattern incisions. The length of the navel stalk may limit any transposition of this structure. Accordingly, one must plan for sitting the navel in an aesthetically pleasing location to complement the finished result. The umbilicus is typically inset along a horizontal line that spans the iliac crests. This will result in the most natural appearance for most individuals. A location 10 cm above the anterior vulvar commissure would result in a placement that is unnaturally low. The other options would yield a position of the umbilicus that is too high.
A 51-year-old woman comes to the office for consultation for abdominal and lower extremity liposuction. The procedure is expected to last approximately 2.5 hours. BMI is 30 kg/m2. The patient takes an oral contraceptive. The patient reports having had a small venous thromboembolism (VTE) during lumpectomy for breast cancer that took place in her early 40s. Which of the following factors increases the risk of VTE and Caprini risk assessment score most significantly?
A) Age
B) History of malignancy
C) History of VTE
D) Length of surgery
E) Use of an oral contraceptive
The correct response is Option C.
In this patient, the highest Caprini risk factor is the history of a VTE, which carries a score of 3. The length of surgery is greater than 45 minutes so it would be considered major and would carry a score of 2, as would her history of malignancy. Age, obesity, and contraceptive use all carry a score of 1. This gives the patient a Caprini score of 10.
Which of the following symptoms meet the current Medicare guidelines for approval of abdominal lipectomy/panniculectomy following massive weight loss?
A) Neck and back pain
B) Psychological distress
C) Unsatisfactory appearance
D) Diastasis recti
E) Recurrent intertrigo
The correct response is Option E.
Medically necessary criteria for Medicare approval of abdominal lipectomy/panniculectomy include: Inability to walk normally Chronic pain and ulceration created by the abdominal skin fold When the panniculus hangs below the level of the pubis Intertrigo of the pannus that is persistent or recurrent over a 3-month period while receiving appropriate medical therapy Stable weight for at least 6 months and 18 months after gastric bypass surgery According to Medicare guidelines, the other four options listed are not considered reasons that make this procedure medically necessary: Treatment of neck and back pain Repairing abdominal wall laxity or diastasis recti Improving appearance Treating psychological symptomatology
A 48-year-old woman undergoes liposuction of the abdomen, flanks, and thighs. Liposuction is performed using 4 L of infiltration fluid. Each liter is mixed with 50 mL of 2% plain lidocaine and 1 mL of 1:1000 epinephrine. At which of the following times after infiltration are concentrations of lidocaine in the blood expected to be the highest in this patient?
A) Immediately after injection
B) 1 hour after surgery
C) 2 to 4 hours after surgery
D) 8 to 18 hours after surgery
E) 24 to 48 hours after surgery
The correct response is Option D.
The safe dosage of lidocaine in liposuction is 35 to 55 mg/kg. Peak lidocaine levels are reported to be 8 to 18 hours after infiltration. Oftentimes, patients are discharged to home when peak levels occur. Surgeons should keep this in mind when calculating lidocaine dosage.
A 35-year-old woman comes to the office for consultation regarding a tummy tuck. She wants the scar as low as possible, but she does not want a lower vertical midline scar. Physical examination shows mild upper and lower abdominal skin excess and rectus abdominis diastasis. BMI is 27 kg/m2. Abdominoplasty and repair of diastasis are planned. Intraoperatively, there is marked tension on the lower central abdominal flap closure. Which of the following is the most appropriate maneuver to decrease the tension on the repair?
A) Creation of a 3-cm transverse umbilical opening
B) Liposuction of the upper abdomen
C) Relaxing incision of the external oblique fascia
D) Scoring of Scarpa fascia to the dermis
E) Use of progressive tension sutures
The correct response is Option E.
Progressive tension sutures are placed from Scarpa’s fascia to the abdominal wall fascia. This helps close the dead space, minimize flap movement, and minimize seroma rate. When placing these sutures with progressive tension, final tension on the abdominal suture line can be lessened. In so doing, healing complications can be reduced. The more common method for reducing tension on flap closure is to close the native umbilical skin opening in a vertical direction. This technique leaves a vertical incision in the midline of the abdominal flap. The need for revision of this scar is not infrequent. Further, most patients want to avoid this scar. Creating a 3-cm transverse incision for the umbilicus would decrease the tension on the flap; however, the appearance of the umbilicus would be aesthetically unacceptable. Relaxing incision of the external oblique fascia is used for closure of ventral herniorrhaphy and would not lessen skin flap tension. Scoring Scarpa’s fascia to the dermis would injure the subdermal vascular plexus, on which the vascularity of the abdominal flap depends. Upper abdominal liposuction can be performed at the same time as abdominoplasty, provided care is taken to maximize preservation of the lateral rectus perforators. It would not be a solution to minimize skin tension.
Compared with liposuction, which of the following is the greatest advantage of cryolipolysis?
A) No procedural discomfort
B) No risk of bruising
C) No risk of posttreatment swelling
D) No surgical intervention
E) Shorter duration of treatment time
The correct response is Option D.
Nonsurgical fat freezing treatment (CoolSculpting) is a method of noninvasive fat reduction that occurs via the use of cryolipolysis. It is a noninvasive technique that takes place in an office setting and does not involve the use of surgery. Following CoolSculpting treatment, patients have some aspect of bruising and swelling, which can last for up to several weeks. Results of CoolSculpting treatments typically take 3 to 4 months to develop. Results are additive, however, with multiple treatments. CoolSculpting involves the utilization of different applicators that have been developed to treat various parts of the body effectively. Each actual treatment is for 1 hour; however, most areas of the body may require multiple treatments to be effectively managed. Treatment times for an abdomen can range from 2 to 6 hours alone, whereas outer thighs are treated for at least 2 hours per side and inner thighs at least 1 hour per side. Although not all of these treatments need to be performed in one sitting, the total time for CoolSculpting treatments for most areas of the body are much longer than it would take to surgically perform liposuction. In general, however, CoolSculpting is a less expensive treatment option compared with liposuction as there is no fee necessary for anesthesia or operating-room costs.
During routine brachioplasty, which of the following nerves is/are most likely at risk during typical dissection?
A) Lateral antebrachial cutaneous nerve
B) Medial antebrachial cutaneous nerve
C) Sensory branches of the axillary nerve
D) Sensory branches of the radial nerve
The correct response is Option B.
The medial antebrachial nerve is most at risk for injury during routine brachioplasty surgery secondary to its superficial location within the subcutaneous tissue within the area of typical skin and soft-tissue excision. This nerve arises from the medial cord of the brachial plexus 78% of the time and from the lower trunk in 22%. After emerging from the axilla, the medial antebrachial cutaneous nerve travels medial to the brachial artery and lies adjacent to the basilic vein at the distal upper arm. In the distal or mid brachium, this nerve pierces the deep fascia to become very superficial running above the deep fascia at an average of 14 cm proximal to the medial epicondyle. Despite some minor anatomical variability, this nerve has been found to be consistently present in the deep plane of dissection for the standard brachioplasty technique.
A 34-year-old woman is evaluated for body contouring after Roux-en-y gastric bypass surgery 6 months ago. There is no evidence of malabsorption. BMI is 36.3 kg/m2. She had a 75-lb (34-kg) weight loss and is actively losing weight. The patient reports low back pain. Which of the following is the most appropriate next step in management?
A) Liposuction
B) Panniculectomy
C) Revision of the gastric bypass surgery
D) Upper GI series
E) Observation
The correct response is Option E.
After bariatric surgery, patients can continue to lose weight as a result of the surgical procedure for approximately 2 years. Thus, most recommendations call for waiting until patients are 12 to 18 months out from their bariatric surgery and at a stable weight for 3 to 6 months. Ideally, patients should be within 10 to 15% of their goal weight. In this case, the patient is still within the time frame of active weight loss, and notes that she is actively losing weight. Thus, the appropriate answer is to wait until weight loss has stabilized. Because this patient is actively losing weight and there are no clinical findings of any issues such as malabsorption, there is no indication currently to evaluate her with an upper GI series or revise her bypass. In addition, as noted above, the risks for surgery are increased at this patient’s BMI. Thus, elective liposuction or panniculectomy is not appropriate at this time. Furthermore, because the patient is actively losing weight, the risk for revision surgery to address additional skin laxity that may develop with further weight loss makes undertaking these procedures not appropriate at this point in time.
Compared with standard suction-assisted lipectomy, laser-assisted liposuction has been shown to decrease which of the following?
A) Contour irregularities
B) Ecchymosis
C) Postoperative pain
D) Skin necrosis
E) Swelling
The correct response is Option C.
A prospective, randomized, double-blind study involving human subjects compared the effects of laser-assisted lipoplasty with suction-assisted lipoplasty. No significant difference was noted between the two groups with respect to cosmetic outcome, ecchymosis, edema, skin retraction, or surgical time. The only measured potential benefit of the laser-assisted technique was an overall decrease in postoperative pain.
A 35-year-old woman comes to the office for lipodystrophy of the upper arms. Physical examination shows negligible skin laxity; pinch test shows a thickness of 3 cm of the entire upper arm and the chest wall. Which of the following is the most appropriate surgical intervention?
A) Extended brachioplasty
B) Limited medial brachioplasty
C) Mini brachioplasty
D) Suction-assisted lipectomy
E) Traditional brachioplasty
The correct response is Option D.
Skin laxity is the single greatest determinant of whether liposuction is an appropriate modality in an algorithmic approach to upper arm lipodystrophy. The determination of excessive fat can be made by the pinch test, and patients with greater than 1.5 cm of fat on a pinch test may be candidates. The classification of lipodystrophy, described by Rohrich et al., includes skin excess, fat excess, and the location of skin excess. Where there is skin excess, the skin must be excised for a favorable result. Liposuction alone can exacerbate the appearance and presence of excess skin. Similarly, skin laxity is a predictor of liposuction success. With marked laxity, the skin is unlikely to have enough elastic properties to retract. Although there are some papers that show increased retraction of skin with laser liposuction, this has not been shown to be a consistent result in large-scale studies.
A 37-year-old woman reports nontender swelling of the lumbar area after undergoing lower body lift following massive weight loss. Examination shows tense swelling and a positive fluid wave test. Percutaneous needle aspiration is performed on a weekly basis, and fluid is still present after three aspirations of 150 mL each of a clear, yellowish serum. Which of the following is the most appropriate next step in management?
A) Compression
B) Operative incision and drainage
C) Placement of a closed suction drain tube
D) Use of an ipsilateral gluteus maximus muscle advancement flap
The correct response is Option C.
Among the most common complications following body contouring for post-massive weight loss-induced skin laxity is seroma, occurring in up to 35 to 50% of patients. To minimize the risk for seroma, preoperative nutritional repletion, especially for protein, and intraoperative use of closed suction drains, aggressive minimization of dead space, limited degree of skin flap undermining, and use of well-fitted elastic compression garments are among the techniques that are commonly recommended. None of these, even in combination, can completely guarantee the elimination of this complication. After several ineffective aspirations, compression garments alone are not likely to eliminate a seroma for this patient. The most appropriate next management measure for this patient’s seroma is ultrasound-directed percutaneous closed suction drain placement. Operative incision and drainage is not indicated unless the closed drain fails, following failed sclerosant therapy, or if the seroma is shown to be infected. A muscle flap is not indicated in this setting.
A 35-year-old woman with a history of hypertension is evaluated for body contouring. Physical examination shows generalized abdominal adiposity and moderate infraumbilical pannus. The patient undergoes abdominoplasty and large-volume liposuction after induction of epidural anesthesia. A super-wet technique is used and a total volume of 5500 mL is removed. Which of the following factors poses the greatest risk of death for this patient?
A) Abdominoplasty
B) Epidural anesthesia
C) Hypertension
D) Liposuction volume
E) Super-wet technique
The correct response is Option A.
The cumulative effect of multiple procedures performed during a single operation increases the potential that complications may develop. Large-volume liposuction, combined with other procedures such as abdominoplasty, can cause serious complications. Death associated with isolated lipoplasty is rare (0.0021%, or one per 47,415), but mortality increases significantly when lipoplasty is combined with other procedures. When combined with non-abdominoplasty procedures, lipoplasty mortality increases to one per 7314; when combined with abdominoplasty, with or without other procedures, the lipoplasty mortality increases to one per 3281. The presumed benefits of combined procedures must thus be weighed against potential untoward events. Studies indicate that epidural anesthesia combined with the infusion of anesthetic infiltrate provides patients with a consistent intraoperative comfort level. Data from the few anesthesia studies that have specifically assessed patients undergoing liposuction confirm the safety of general anesthesia, epidural anesthesia, spinal anesthesia, moderate sedation, and local anesthesia for this procedure. It should be noted, however, that epidural anesthesia and spinal anesthesia can cause vasodilation and hypotension, thereby necessitating the administration of excess fluid and increasing the risk of fluid overload. Based on the patient’s history, physical examination, review of systems, laboratory testing, and/or a medical specialist’s evaluation, the physician should select the patient’s American Society of Anesthesiologists (ASA) physical classification rating: Type 1: A normal healthy patient; Type 2: A patient with mild systemic disease; Type 3: A patient with severe systemic disease; Type 4: A patient with severe systemic disease that is a constant threat to life. ASA Type 1 and Type 2 patients are candidates for ambulatory and office-based surgery. The patient described is a Type 2 patient, a classification rating that represents patients who have any of the following conditions that are under control without systemic compromise: diabetes mellitus, hypertension, asthma, gastroesophageal reflux disease, peptic ulcer disease, hematologic disorders, arthritis, and neuropathy. Large-volume liposuction is defined as the removal of 5000 mL or greater of total aspirate during a single procedure. A review of the scientific literature shows that there are no scientific data available to support a specific volume maximum at which point liposuction is no longer safe. The super-wet technique, introduced in the mid-1980s, uses larger volumes of subcutaneous infiltrate, whereby 1 to 2 mL of solution is infused for each 1 mL of fat to be removed. The infiltrate solution consists of saline or Ringer’s lactate with epinephrine and, in some cases, lidocaine. Using this method, blood loss generally decreases to less than 1 to 2% of the aspirate volume.
An otherwise healthy 41-year-old woman who underwent Roux-en-Y gastric bypass surgery 24 months ago, followed by a 120-lb (54-kg) weight loss that she maintained for 6 months, undergoes plastic surgery evaluation for a panniculectomy. Medical history includes hypothyroidism that is controlled with levothyroxine. Preoperative cardiovascular examination shows no abnormalities, and results of a pregnancy test on the day of surgery are negative. She undergoes panniculectomy and thigh lift, and on extubation, the patient is lethargic and confused. ECG shows sinus tachycardia, and she remains somnolent and confused. Analysis of thyroid-stimulating hormone and cardiac enzymes, chest x-ray study, and ventilation-perfusion scan show no abnormalities. Which of the following is the most likely diagnosis?
A) Acute thyroiditis
B) Diabetic ketosis
C) Pulmonary embolism
D) Undiagnosed pregnancy
E) Vitamin B1 (thiamine) deficiency
The correct response is Option E.
Thiamine deficiency is most often identified shortly after bariatric surgery but can be diagnosed later. Some patients can develop Wernicke-Korsakoff encephalopathy (WKE). Body stores of thiamine can last from 3 to 6 weeks, and thiamine deficiency is more associated with decreased dietary intake. Although clinical manifestations are very uncommon, and WKE is considered a rare complication, approximately 11% of patients who have undergone Roux-en-Y gastric bypass surgery and take vitamin supplementation show evidence of thiamine deficiency 2 years postoperatively. The hallmark of thiamine deficiency is neurologic symptoms, but in contrast to WKE, patients rarely exhibit confusion, ataxia, and oculomotor abnormalities. If thiamine deficiency is not recognized and treated, it can have devastating results, including irreversible brain damage and death. Full nutritional workup of patients is critical. Confusion is a symptom of diabetic ketosis, but diabetic ketosis is notable for signs of dehydration and excessive thirst or urination, and is associated with Kussmaul respirations. Acute thyroiditis has symptoms of pain and swelling of the anterior neck. Pulmonary embolism can have symptoms of respiratory distress and right-sided heart strain. Early pregnancy often results in nausea, but not lethargy and confusion.
A 56-year-old woman comes to the office after gastric bypass surgery with a weight loss of 155 lb (70 kg). Weight is 143 lb (65 kg) and BMI is 24 kg/m2. She desires an improved appearance of the upper arms. A photograph is shown. Which of the following is the most appropriate surgical correction of this deformity?
A) Liposuction alone
B) Liposuction followed by brachioplasty
C) Limited medial brachioplasty
D) Full brachioplasty
The correct response is Option D.
The most appropriate management for this condition is brachioplasty. Surgical management of the upper arm, particularly after massive weight loss, is dependent upon the ratio of fat and skin laxity. There are several classifications, but all address this ratio. Those with a great deal of skin laxity and little fat are best treated by direct excision (brachioplasty). Those patients who have little skin laxity (and good skin tone) and marked fat may benefit from liposuction alone. Those patients in the middle, with skin laxity and residual upper arm fat, are likely to benefit from a combination approach, either in a single or staged fashion. In this case, the patient demonstrates considerable skin laxity and has little extra fat, so a dermatolipectomy alone will address her deformity. A limited medial brachioplasty is useful for patients with skin laxity primarily in the proximal third of the arm and involves resection of a vertical ellipse of skin, leaving the scar in the apex of the axilla. The patient described here has skin laxity throughout the upper arm, which would not be adequately addressed with a medial brachioplasty. Liposuction followed by brachioplasty in a staged fashion will not improve her outcome and will only serve to increase the cumulative risks of two surgeries. Liposuction alone does not address the underlying issue of skin laxity. The patient’s age and her history of obesity/massive weight loss severely decrease the ability of her skin to retract after liposuction.
A 60-year-old woman comes to the office for evaluation of a poor outcome after liposuction of the arms. She says she is dissatisfied with the marked laxity of the skin of her arms. A photograph is shown. History includes gastric bypass surgery followed by a 100-lb (45.3-kg) weight loss. BMI is 28 kg/m2. Which of the following procedures is most appropriate to improve contour of the arm in this patient?
A) Laser-assisted liposuction
B) Lipobrachioplasty
C) Radiofrequency treatment (Thermage)
D) T-incision brachioplasty
E) Ultrasound-assisted liposuction
The correct response is Option D.
Traditional brachioplasty comprises a T-shaped scar along the length of the arm and the axilla. This patient has excess skin on her arm, which dictates the necessity for an excisional procedure. Further liposuction of any modality will exaggerate her presentation further, including Vaser liposuction, a form of ultrasound-assisted liposuction, and laser-assisted liposuction, both of which are reported to tighten skin through heating its undersurface. There is no evidence to support Thermage as an effective treatment for lax skin. Lipobrachioplasty is a technique which safely combines liposuction with excisional surgery, performing liposuction on the proposed area to be excised. In a thinned arm, potential risks of neuropathy and seroma that accompany liposuction are unnecessary in a patient with lax skin that requires excision to improve contour. Limited incision brachioplasty with excision limited to an ellipse in the axilla, with or without liposuction, provides very limited results with regard to improving overall arm contour, particularly with moderate-to-severe skin redundancy.
A 55-year-old woman comes to the office for consultation about arm contouring. She underwent gastric bypass surgery 18 months ago, followed by a 100-lb (45-kg) weight loss. She says she has difficulty finding clothing that fits her upper arms. A photograph is shown. Physical examination shows skin laxity and lipodystrophy of the upper arms. Brachioplasty with a T-scar and posterior liposuction is planned. Which of the following complications is most likely to occur in this patient?
A) Cellulitis
B) Lymphedema
C) Numbness
D) Thromboembolism
E) Wound dehiscence
The correct response is Option E.
The most likely risk of a combination brachioplasty liposuction procedure is wound dehiscence. Wound dehiscence has been most commonly reported when liposuction is performed in conjunction with brachioplasty, and most commonly reported with the excisional technique alone. Dehiscence most often occurs in the axilla at the T point in traditional brachioplasty and in the axilla in the L-brachioplasty approach.
Lymphedema also may occur after brachioplasty with or without liposuction and is also often temporary. There is no increased risk with liposuction. Lymphedema occurs because of scarring around the axillary lymph nodes. Cellulitis may also be associated with lymphatic obstruction or interruption in the arm.
Numbness is a common complication following brachioplasty but is often temporary in nature. The medial antebrachial cutaneous nerve is located within the field of surgery in the distal arm and may undergo traction injury or laceration. Thromboembolism is a rare occurrence after brachioplasty.
For each patient with excessive abdominal tissue, select the most appropriate surgical procedure (A €“E).
A ) Abdominoplasty
B ) Abdominoplasty and liposuction
C ) Circumferential lower body lift (hemi-body lift)
D ) Liposuction
E ) Panniculectomy
A 49-year-old woman who underwent gastric bypass surgery. She has lost 100 lb, going from a body mass index (BMI) of 45 kg/m2 to 28 kg/m2, and now has excess anterior abdominal and buttock tissue.
A 55-year-old man with a BMI of 40 kg/m2, who has had episodes of severe intertrigo and skin infections from overhanging skin and fat of the anterior abdomen. He has smoked one half of a pack of cigarettes daily for five years.
The correct response for Item 1 is Option C and for Item 2 is Option E.
For the massive weight-loss patient, only a circumferential lower body lift adequately addresses excessive tissue of both the anterior and posterior trunk.
For the patient with skin infections, a panniculectomy will address the excessive abdominal pannus, which is producing the symptoms described. In a patient with a history of smoking, there is an increased risk of wound-healing complications and skin necrosis. Other surgical options that involve undermining tissues and raising skin flaps will further jeopardize the vascularity and healing of the overlying skin. Liposuction would address the excess adipose tissue but not the excess skin. A straight panniculectomy without undermining will minimize the risk of wound complications in a patient with a history of smoking. Patients who smoke should be counseled on the importance of smoking cessation at least four weeks before and after elective surgery.
A 50-year-old woman comes to the office for consultation regarding body contouring one year after undergoing a gastric bypass procedure. She has lost 160 lb since the procedure was performed. Preoperative photographs are shown above. Which of the following is the most appropriate surgical procedure for improvement of the thigh and buttock regions in this patient?
(A) Direct excision of gluteal skin folds
(B) Suspension of a dermal fat flap
(C) Augmentation of the gluteal region
(D) Liposuction
(E) Lower body lift
The correct response is Option E.
In this patient, the best option for improvement of the buttock and thigh regions is a lower body lift. This procedure is indicated in patients with relaxation and resultant ptosis of the buttock and thigh tissues. In addition to moderate or more severe skin laxity, the potential for laxity to develop after liposuction is an indication for an excisional lifting procedure over liposuction alone. In this patient, placing the incision at the level used in the lower body lift will create a better hip contour as well as lift the descended thigh and buttock tissue. This can be combined with thigh liposuction to address any thigh lipodystrophy.
Direct excision of the gluteal fold can result in flattening of the buttocks, asymmetry, and hypertrophic scarring. Suspension of a dermal-fat flap is performed using a gluteal fold incision. Flattening of the buttocks and loss of gluteal fold definition, as well as hypertrophic scarring, can also result from this technique. Gluteal implants have the associated risks of implant extrusion, infection, and malposition. Furthermore, these three techniques do not address the primary pathology of the descent of tissue and do not restore the tissues to a more anatomic position. Liposuction can be used in the patient with good skin quality where adequate retraction is likely. However, if there is potential for skin laxity, liposuction may result in a worsening of the deformity as the tissue is deflated. Liposuction also carries a risk of worsening buttock ptosis, loss of gluteal fold definition, and contour irregularities. Liposuction can be used as an adjunct to excisional techniques.
