Body Contour - Abdominoplasty Liposuction Flashcards
In patients undergoing brachioplasty, which of the following is the most common long-term unfavorable result?
(A) Intermittent sharp pain in the arm
(B) Lymphedema of the hand and forearm
(C) Numbness of the medial arm
(D) Seroma of the upper arm
(E) Widening of the scar
The correct response is Option E.
Widened scars are the most common long-term complication following brachioplasty. These scars, which are typically located on the posteromedial upper arms, are red and visible for a minimum of one year and in fact may never completely fade. Patients should be informed of the potential for widened, visible scars prior to undergoing the procedure.
Intermittent sharp pain, lymphedema, numbness, and seromas can be complications of brachioplasty but are most likely to be temporary and to resolve within one to four weeks.
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 42-year-old man comes to the office because of numbness and pain near the elbow 1 year after undergoing bilateral L-brachioplasty following a 150-lb (68-kg) weight loss. Current weight is 200 lb (90 kg) and BMI is 32 kg/m2. Nerve electrical conduction studies are most likely to demonstrate injury to which of the following sensory nerves?
A) Lateral antebrachial cutaneous
B) Medial antebrachial cutaneous
C) Posterior antebrachial cutaneous
D) Radial dorsal cutaneous
E) Ulnar dorsal cutaneous
The correct response is Option B.
The demand for brachioplasty in the United States has increased as the number of patients undergoing bariatric surgery has increased. While brachioplasty is considered a safe and effective method of treating upper arm skin excess, the reported complication rate ranges from 25 to 40%. Most common complications of brachioplasty are considered minor and include seroma, poor scarring, edema, wound dehiscence, and underresection. The most common major complication is cutaneous nerve injury, which can occur in up to 5% of patients.
Medial placement of the brachioplasty incision in the bicipital groove is preferred because the ultimate scar will be hidden when the arm is adducted. Medial placement of the incision may damage the cutaneous nerves that run in this area. Both the medial antebrachial cutaneous nerve and the medial brachial cutaneous nerve arise from the medial cord of the brachial plexus. The medial brachial cutaneous nerve runs with the basilic vein and sends two to four branches to the skin 7 cm proximal to the medial epicondyle. Another three to five branches pierce the fascia to innervate the skin at about 15 cm proximal to the medial epicondyle. The medial antebrachial cutaneous nerve runs in close proximity with the intramuscular septum and penetrates the fascia approximately 14 cm proximal to the medial epicondyle. At this point, the nerve runs superficially and is at risk for injury.
While injuries to motor branches of the median and ulnar nerve have been reported, these branches run deep to the brachial fascia and are not injured unless the intramuscular septum is inadvertently punctured.
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.
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.
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.
When performing suction lipectomy using the superwet technique, the amount of blood loss in the suction aspirate is closest to which of the following?
(A) 0%
(B) 10%
(C) 20%
(D) 30%
(E) 40%
The correct response is Option A.
With the superwet technique, blood loss is approximately 1% of the suction aspirate. This technique uses a 1:1 ratio of subcutaneous infiltrate to aspirate. The infiltrate consists of saline or Ringer’s lactate solution, epinephrine, and in some cases lidocaine.
The first method of suction lipectomy, the dry technique, was associated with blood loss of 20% to 45% in the suction aspirate as well as substantial swelling and discoloration. It was performed under general anesthesia without infiltration of subcutaneous solutions before insertion of the suction lipectomy cannula. Except in limited applications, this approach has been abandoned.
The wet technique is associated with blood loss of 4% to 30% of the aspirate. In this technique, 200 to 300 mL of infiltrate or wetting solution, with or without additives, is injected into the operative field before insertion of the suction lipectomy cannula. Small doses of the vasoconstrictor epinephrine are added to the infiltrate.
Like the superwet technique, tumescent suction lipectomy is associated with blood loss of approximately 1% in the suction aspirate. However, it uses more infiltrate, up to 3 or 4 mL of infiltrate for each planned milliliter of aspirate.
A 44-year-old woman is brought to the emergency department because of the sudden onset of heart palpitations and anxiety 12 hours after undergoing abdominoplasty and liposuction. History includes breast cancer. She uses a transdermal patch for contraception. Height is 5 ft 5 in (165 cm) and weight is 152 lb (69 kg). During the abdominoplasty procedure, 4 L of Ringer’s lactate containing lidocaine 25 mg/L and epinephrine 1 mg/L were infused prior to the first incision, and 4.1 L of aspirate were obtained. Recovery had been uneventful until the current episode. Which of the following is the most appropriate management?
A ) Administration of 0.5 mg alprazolam (Xanax)
B ) CT scan of the chest
C ) Determination of serum lidocaine concentration in the blood
D ) Doppler ultrasonography of the lower extremities
E ) Reassurance and observation
The correct response is Option B.
The patient described most likely has an acute pulmonary embolism (PE) and should receive urgent medical attention at the nearest emergency department. Her age, recent diagnosis of breast cancer, and estrogen-based contraceptive use places her at moderate-to-high risk for deep venous thrombosis (DVT) and/or PE following surgery. In addition, the combination of large-volume liposuction and full abdominoplasty as a single procedure further increases her risk for these complications. Heart palpitations and anxiety are common complaints in patients experiencing a PE, as are shortness of breath and hyperventilation, but the diagnosis should not be overlooked in a situation like this, even if it is not a presenting symptom. A CT scan of her chest as dictated in a PE protocol is the appropriate diagnostic study to evaluate for PE and will provide the necessary justification to initiate anticoagulation therapy.
Advising her to go to the nearest emergency department to be monitored for lidocaine toxicity is not appropriate because lidocaine toxicity is not likely to be the correct diagnosis. Although serum lidocaine concentrations peak approximately 12 hours postoperatively, the lidocaine dose that she received was well within the established limits of safe lidocaine administration based on her body weight (7 mg/kg with the use of epinephrine).
Attributing her complaints to a preexisting anxiety disorder could have disastrous consequences in the scenario described. The patient is at a significant risk for a PE based on her medical history and her procedure; therefore, she should receive urgent medical care. Alprazolam (Xanax) is a respiratory depressant that could exacerbate her apparent hypoxia.
Doppler ultrasonography would be useful to evaluate for a lower extremity DVT, but it is not the most appropriate study to diagnose a PE.
Reassurance over the phone and arranging to see the patient in your office early the next morning is inappropriate, as any delay in diagnosis of such a serious complication could be potentially lethal.
Suction lipectomy is a viable means of breast reduction because the percentage of the female breast that is comprised of fat is closest to
(A) 10%
(B) 25%
(C) 50%
(D) 75%
(E) 90%
The correct response is Option C.
Suction lipectomy can be performed to remove fatty tissue in the breast without disturbing parenchymal tissue. It is an attractive option for breast reduction in women who would like to avoid the scarring associated with traditional surgical techniques. According to the results of one recent study that involved a significant population of overweight women, the mean percentage of fat in the breast was 61%. Another study of women predominantly of normal body weight showed a mean percentage of fat of 48%. In addition, these studies showed that younger patients have significant amounts of fat in the breast, even though the percentage of fat was shown to increase with age. Body mass index had more influence on the percentage of breast fat than age, and the amount of fat in the breast could not be accurately assessed on physical examination.
One clinical study reported that breast reduction via suction lipectomy alone produced the best results in women who had well-located or slightly ptotic nipples. Benefits of this technique include the avoidance of scarring and compromise to the blood supply and nerves to the nipple. However, many surgeons remained concerned about the effectiveness of suction lipectomy alone in patients with very large breasts, as well as the lack of skin excision, the potential for induction of microcalcifications, and the viability of pathologic examination of removed fat.
A 42-year-old woman is undergoing brachioplasty after a massive weight loss. The surgeon is most likely to avoid injury to the medial antebrachial cutaneous nerve during the procedure if he or she is able to identify it in the elbow at which of the following locations?
A) Deep to the deep fascia traveling with the basilic vein
B) Deep to the deep fascia traveling with the cephalic vein
C) Superficial to the deep fascia traveling with the basilic vein
D) Superficial to the deep fascia traveling with the cephalic vein
The correct response is Option C.
The position of the medial antebrachial cutaneous nerve (MABC) makes it vulnerable to injury during a brachioplasty. Understanding its course and relationship to other structures allows the surgeon to identify and protect it. The MABC is a sensory nerve. It is a terminal branch of the medial cord of the brachial plexus. It travels with the basilic vein medial to the biceps brachii muscle, and it pierces the fascia at the basilic hiatus proximal to the elbow. Injury to the MABC can cause areas of numbness of the median forearm, as well as painful neuromas. The MABC is best identified in the distal aspect of the brachioplasty incision with the basilic vein and protected during the dissection.
A 38-year-old woman comes to the office because of excess fullness of the proximal posterior arm. Pinch test shows a thickness of greater than 2 cm, and skin laxity is not excessive. Liposuction is planned. Which of the following is the most likely complication of liposuction of the upper extremity?
A) Contour irregularities
B) Hyperpigmentation
C) Injury to the ulnar nerve
D) Lymphedema
E) Seroma
The correct response is Option A.
The most common complication associated with liposuction of the arm is areas of overresection resulting in contour irregularities. Because such irregularities can be due to postoperative swelling, they should be treated conservatively for at least 6 months after surgery. Treatment may consist of fat grafting if contour abnormalities persist after 6 months. Early treatment may include lymphatic massage.
Although hyperpigmentation is possible, it is more commonly seen in the medial thigh in association with ultrasound-assisted liposuction. Seromas are rare in the upper extremity. Injury to the ulnar nerve at the elbow is possible, but it has not been reported. Care should be taken to avoid the nerve in placement of the cannula. While lymphedema is possible, if liposuction of the arm is limited to the posterior aspect, where major lymphatic channels are avoided, it can be prevented. Transient postoperative swelling is expected.
A 50-year-old woman is scheduled to undergo a cosmetic procedure in an ambulatory surgery center (ASC). The patient is concerned about her risk of dying during this procedure. This patient?s postoperative risk of death from a pulmonary embolism is highest if she undergoes which of the following procedures in an ASC?
A) Abdominoplasty
B) Augmentation mammaplasty
C) Rhinoplasty
D) Rhytidectomy
E) Suction lipectomy
The correct response is Option A.
Abdominoplasty is the procedure associated most frequently with postoperative mortality from a pulmonary embolism in an ASC.
The American Association for Accreditation of Ambulatory Surgery Facilities, Inc. (AAAASF) has collected statistics on morbidity and mortality for its accredited facilities. Mortality from office-based surgery is extremely rare. From 2001 to 2006, there were over 1 million outpatient procedures performed with 23 deaths. Pulmonary embolism was the cause in 13 of the 23 deaths. Twelve of the 13 pulmonary embolism deaths were associated with abdominoplasty alone or in conjunction with another procedure.
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.
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.
An otherwise healthy 35-year-old man comes to the office because of a 15-year history of bilateral Grade III gynecomastia. Height is 5 ft 10 in (178 cm) and weight is 187 lb (85 kg). BMI is 27 kg/m2. Physical examination shows breast enlargement with skin redundancy and palpable glandular and fatty tissue. Ultrasound-assisted lipectomy is planned because the patient wishes to avoid visible scars. Which of the following is most likely to minimize the need for skin resection?
A)Disruption of the inframammary fold
B)High energy setting
C)Peripheral feathering with standard liposuction
D)Treatment of the intermediate fat layer
E)Tumescent infiltration with a 3:1 ratio
The correct response is Option A.
Although surgery remains the mainstay of treatment for gynecomastia in this country, results have been inconsistent, with reported dissatisfaction rates as high as 50%. Common aesthetic problems reported after surgery include unacceptable scarring and nipple and areolar deformities such as tethering and malposition. As a result, less invasive techniques have evolved and are now the mainstay of treatment for all but the most severe forms of gynecomastia.
The use of ultrasound-assisted lipectomy has improved the outcomes in the treatment of all grades of gynecomastia. In the more severe grades, certain maneuvers will improve skin retraction and redraping and may thus eliminate the need for a subsequent procedure for skin excision. While fatty and fibrous tissue is best approached from a deeper subcutaneous plane, transition to a subdermal plane can allow for greater skin retraction. Moreover, disruption of the inframammary fold is essential in that it allows the skin to drape more naturally onto the abdomen, which is typical of a male breast.
The use of wetting solutions is imperative with ultrasound-assisted lipectomy to avoid burns. Both superwet (1:1) and tumescent (3:1) techniques are acceptable. The power of the unit should generally not exceed 90% to avoid burns and dermal injuries. Peripheral feathering improves contour, providing a smoother transition to the outer border of the breast, but does not specifically address skin excess.
A 45-year-old woman who has had a 100-lb weight loss since undergoing gastric banding two years ago comes to the office for consultation regarding loose skin on her upper arms. Physical examination shows significant ptosis of the posteromedial aspect of the upper arms and relaxation of the soft tissue. Fascia in which of the following regions is also relaxed in this patient and is appropriate for use as an anchor during brachioplasty to reduce widening and hypertrophy of the scars?
(A) Axillary
(B) Bicipital
(C) Deltoid
(D) Pectoral
(E) Tricipital
The correct response is Option A.
An important etiologic mechanism of the aesthetic arm deformity is relaxation of a longitudinal fascial system sling that extends from the clavicle to the soft tissues of the posteromedial aspect of the arm via the clavipectoral and axillary fascia. Reanchoring the soft tissues of the posteromedial aspect of the arm to the axillary fascia with nonabsorbable sutures addresses the relaxation of the axillary fascia sling and forms the basis for the anchor brachioplasty. Similarly to anchoring the soft tissues of the medial aspect of the thigh to the Colles fascia (perineum) in medial thigh lifts, fascial anchoring in brachioplasties provides more predictable results while reducing complications.
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 30-year-old woman has numbness of the forearm following a brachioplasty procedure to correct significant skin laxity. Which of the following nerves was most likely injured during the procedure?
A ) Axillary
B ) Intercostal brachial
C ) Medial antebrachial cutaneous
D ) Posterior interosseous
E ) Ulnar
The correct response is Option C.
The medial antebrachial cutaneous (MABC) nerve may be located within the resection area of the arm during brachioplasty, leading to regional paresthesia in the upper arm and the anterior proximal forearm. The MABC nerve exits 14 cm proximal to the medial epicondyle and tends to run in close proximity to the intramuscular septum. Patients may be treated with hand therapy and local massage, as well as medications such as gabapentin (Neurontin), if needed. Sensation often improves with the passage of time.
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 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 41-year-old woman comes to the office for consultation regarding irregular skin tone and uneven skin surface on the outer thighs one year after she underwent liposuction of the hips and thighs. On physical examination, the irregularities are radially oriented around a single small scar approximately 1 cm wide. No other scars are visible. The most likely explanation for these findings is use of which of the following during the liposuction procedure?
(A) Deep large cannula suction with cross-tunneling
(B) Fine cannula suction with cross-tunneling
(C) Fine cannula suction without cross-tunneling
(D) Superficial large cannula suction through a single port site
(E) Superficial large cannula suction with cross-tunneling
The correct response is Option D.
One of the most common deformities of liposuction is surface irregularity, which can result from several etiologies. A large cannula will create a large furrow that may be visualized if the liposuction is not done evenly. Use of a single port may also lead to irregularities because the suctioning is done from only one angle. Superficial suctioning is also more prone to visible irregularities. The best way to avoid this problem is to use small cannulas in the deep fat, with cross-tunneling from two sites such that the tunnels are at right angles to each other.
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 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.
A 50-year-old man who weighs 155.5 lb (70 kg) is scheduled to undergo liposuction of the abdomen, flanks, and chest with administration of epinephrine and lidocaine for tumescent anesthesia. Which of the following amounts of lidocaine is the maximum for this patient?
(A) 7 mg
(B) 35 mg
(C) 150 mg
(D) 490 mg
(E) 2450 mg
The correct response is Option E.
For subcutaneous infiltration with 1% lidocaine with 1:100,000 epinephrine, 7 mg/kg of lidocaine is generally recommended. It has been shown, however, that the use of “tumescent fluid” with 1:1,000,000 epinephrine can be safely given with lidocaine doses as high as 35 mg/kg. Lidocaine toxicity can have an excitatory effect on the nervous system, such as tingling, numbness, mental status changes, and, eventually, seizures. Subsequent manifestations include CNS depression with cessation of convulsions, unconsciousness, and respiratory depression or arrest. In the heart, this mechanism depresses Vmax (i.e., the rate of depolarization during phase 0 of the cardiac action potential) and might lead to reentrant arrhythmias. Additionally, conduction through the sinus and atrioventricular (AV) nodes is suppressed. Acceleration of the ventricular rate has been reported in patients with atrial arrhythmias. Lidocaine also might elevate fibrillation thresholds. A negative inotropic effect on the myocardium and direct peripheral vasodilation might occur, which can produce hypotension. Lidocaine commonly is associated with sinus tachycardia, whereas bupivacaine has been known to cause ventricular tachycardia and fibrillation. Widening of the PR interval, increased QRS duration, sinus tachycardia, sinus arrest, and partial or complete AV dissociation can be seen.
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.
During suction lipectomy using tumescent anesthesia, total blood loss is expected to be what percentage of the total aspirate?
(A) 1%
(B) 10%
(C) 20%
(D) 30%
(E) 50%
The correct response is Option A.
The tumescent technique of suction lipectomy uses a dilute solution of lidocaine and epinephrine as infiltrate in the area that is to be suctioned. With this technique, 2 to 3 mL of infiltrate are used for every 1 mL of fluid that is to be aspirated. Blood loss is significantly decreased with this technique; many studies have shown blood loss of only 1% with tumescent anesthesia.
The dry technique of anesthesia is associated with the greatest blood loss, as 20% to 45% of the aspirate consists of blood. The wet technique infiltrates 300 mL of fluid per region and results in aspirate that is comprised of 25% blood.
The superwet technique has a blood-to-aspirate ratio of 3 to 10% and uses an injected volume of 1 mL for every 1 mL of aspirate.
A 42-year-old man develops a dehiscence of the abdominal incision six weeks after undergoing a lower body lift. Medical history includes a 100-lb (45-kg) weight loss during the past three years. Which of the following is the most likely cause of the wound-healing problem?
A ) Hematoma
B ) Patient movement
C ) Seroma
D ) Skin necrosis
E ) Wound infection
The correct response is Option C.
Body lift procedures after massive weight loss have a complication rate of approximately 50%. The most common complication is wound dehiscence, which occurs in greater than 30% of patients. Wound dehiscence can be characterized as either early (in the immediate postoperative period) or late. Early wound dehiscence may be caused by patient movement, while late wound dehiscence is often due to underlying seroma. Although infection and skin necrosis can occur in the postoperative period and result in wound dehiscence, seroma is much more common.
A 35-year-old woman is scheduled to undergo liposuction in an office-based setting. Height is 5 ft 10 in (178 cm) and weight is 185 lb (84 kg). According to the American Society of Plastic Surgeons Committee on Patient Safety, the recommended maximum total volume of aspirate should be limited to which of the following amounts?
A ) 4000 mL
B ) 5000 mL
C ) 6000 mL
D ) 7000 mL
E ) 8000 mL
The correct response is Option B.
In the €œPractice Advisory on Liposuction, € the American Society of Plastic Surgeons Committee on Patient Safety defines large-volume liposuction as more than 5 L of lipoaspirate taken in one operation. Different states may have different regulations regarding liposuction aspirate volume.
Liposuction should be performed in an appropriate facility with qualified staff to monitor postoperative vital signs and urinary output. A postliposuction surgery protocol should be followed to monitor and document any signs of volume overload. These signs include:
increased blood pressure, jugular vein distension, and full bounding pulses
cough, dyspnea, lung crackles, pulmonary edema, and changes in urinary output
The physician should not combine large-volume liposuction with additional procedures because of the risk of severe complications.
A 66-year-old woman undergoes minimal-incision brachioplasty to treat bilateral upper extremity skin laxity. Height is 5 ft 6 in (167.6 cm) and weight is 140 lb (63.5 kg). BMI is 22.6 kg/m2. Which of the following suturing techniques is most appropriate to minimize widening of the scar?
A) Arm dermis to axillary dermis
B) Arm dermis to axillary dermis to axillary fascia
C) Arm dermis to axillary dermis to pectoralis major fascia D) Axillary dermis to lateral pectoralis major tendon
E) Axillary dermis to superficial pectoralis minor fascia
The correct response is Option B.
The popularity of brachioplasty has significantly increased in America over the past decade, in large part because of the number of patients undergoing bariatric surgery for morbid obesity. In this population of patients who have undergone massive weight loss, the severity of excess upper extremity skin mandates a long, often hypertrophic scar in the bicipital groove, which is generally accepted by patients. By contrast, older patients with skin laxity but little lipodystrophy and no history of significant weight change are hard-pressed to accept this visible and often unpredictable scar. For this population, minimal-incision brachioplasty has emerged as an excellent solution and has itself been increasing in popularity over the past few years. In minimal-incision brachioplasty, incisions are limited to the axilla. The procedure is usually combined with suction lipoplasty to remove some excess upper extremity fat, to treat dog ears at the proximal and distal extent of the scar, or to facilitate undermining. Several key maneuvers improve the appearance of the scar and are tantamount to achieving high patient satisfaction after this procedure. The benefit of anchoring the superficial fascial system was first recognized by surgeons performing traditional brachioplasty procedures. A similar concept applies to minimal-incision brachioplasty, where anchoring of the arm and axillary dermis to the superficial fascia is seen to have several advantages. As part of a layered closure, this technique distributes tension in a more even and controlled manner, releasing the high tension on the final skin closure and decreasing the risk of a widened scar. Moreover, these sutures close the dead space within the axilla and recreate the axillary hollow. Suturing the arm dermis to the axillary dermis without fascial reinforcement results in a high-tension closure and often a widened, hypertrophic scar. Suturing the skin to the deeper fascial layers would be difficult and deforming.
A 40-year-old man becomes increasingly disoriented and obtunded 1 day after belt lipectomy. He has had a 200-lb (91-kg) weight loss since undergoing gastric bypass surgery 22 months ago. Which of the following is the most appropriate initial step in management?
A ) Anesthesia consultation
B ) Duplex ultrasonography of the legs
C ) Heparin therapy
D ) Psychiatric evaluation
E ) Thiamine therapy
The correct response is Option E.
Many massive weight-loss patients suffer from malnutrition, including thiamine deficiency, which can lead to Wernicke-Korsakoff encephalopathy. Treatment is intravenous administration of 100 mg/d of thiamine, continuing with 100 mg every 8 hours until resolution of symptoms. Administration of thiamine is low risk and may reverse symptoms. CT scan of the head is worthwhile but can wait until after thiamine is administered. It is possible the patient could have suffered a €œkink € in his carotid or vertebrobasilar system with prone positioning, particularly if the head was positioned to the side and the neck was not in neutral position. Duplex ultrasonography of the legs, which can rule out deep venous thrombosis and possible pulmonary embolism, is recommended if there is a high-risk background, but it is unlikely 1 day after surgery. Therapeutic heparin administration would present a danger for postoperative bleeding only 1 day after belt lipectomy. Metabolic or surgical issues should be addressed before a psychiatrist is involved.
A 53-year-old woman who underwent laparoscopic gastric bypass surgery comes to the office for consultation regarding abdominal contouring. History includes an open cholecystectomy, ventral hernia repair, appendectomy, and caesarean delivery. The presence of which of the following scars on this patient’s abdomen is most likely to result in postoperative wound healing complications?
A) Laparoscopic port scar
B) Pfannenstiel (low transverse) scar
C) Right lower quadrant scar
D) Right subcostal scar
E) Upper midline scar
The correct response is Option D.
The blood supply to the abdominal wall arises from the intercostal arteries, the superior and inferior superficial epigastric arteries, and the perforators from the deep superior epigastric arteries through the rectus abdominis muscle. In a traditional abdominoplasty with undermining of the superior flap up to the costal margin, the superficial inferior epigastric arteries and the perforators that arise from the rectus abdominis muscles are divided. This leaves the abdominal flap to survive on the flow from the intercostal vasculature. The subcostal scar from the prior open cholecystectomy is the most likely scar to pose a problem for wound healing in the patient described. This scar has divided the blood flow through the intercostal circulation; thus, flow inferior to the scar may be unreliable.
The port scars are unlikely to cause problems with blood supply due to their small size. The Pfannenstiel, or low transverse, caesarean section scar will require either inclusion within the tissue to be removed or placement within the inferior incision in the old scar line if it is sufficiently low. Placement of the incision above the old scar may impair the blood flow between the two scars. However, even in the scenario described, it is less likely to cause a healing issue because of the transverse orientation of the scar and the lack of undermining between the new incision and old scar. The right lower quadrant (appendectomy) scar will not be an issue, as this will be removed with the tissue resection. The upper midline scar is not as likely to cause a wound healing issue, as circulation from the intercostal vessels from both sides should supply blood flow to the flap on each side of the midline.
Compared with traditional suction lipectomy, which of the following is more likely to occur with ultrasonic-assisted suction lipectomy?
(A) Contour irregularity
(B) Major blood loss
(C) Nerve injury
(D) Pulmonary edema
(E) Thermal burns
The correct response is Option E.
Ultrasonic-assisted suction lipectomy (UAL) is currently performed as a complement to, not a replacement for, traditional suction lipectomy. This technique involves the transmission of ultrasonic energy via a transducer to cavitate adipocytes and emulsify the liquefied fat, making aspiration of fat easier. UAL is advantageous in removing fat from difficult or fibrous body areas, such as the epigastrium and upper abdomen. It is also purported to stimulate skin retraction after superficial treatment.
Many complications that occur with UAL are similar to those seen with traditional lipectomy procedures, including contour irregularities, perforations, paresthesia and hypoesthesia resulting from nerve injury, seroma formation, and adverse cardiopulmonary effects. In addition, UAL has been shown to elicit greater tissue damage and bleeding than traditional techniques; however, the decrease in hemoglobin level postoperatively is similar with either technique.
UAL is associated with an increased incidence of internal and external cutaneous burns resulting from the intense heat generated by sound waves; this complication does not occur with traditional suction lipectomy. In addition, there are concerns regarding the unknown long-term effects of sound waves and exposure to high temperatures, bond dissociation within molecules, production of free radicals within the body, and other factors.
A 48-year-old woman is scheduled to undergo abdominoplasty. She has smoked one pack of cigarettes daily for the past 10 years. During the preoperative visit, she informs the plastic surgeon that she has been on a nicotine patch and has not been smoking for 3 weeks. Which of the following mechanisms is most likely to cause wound healing complications in this patient?
A ) Decreased availability of hemoglobin
B ) Decreased red blood cell deformability
C ) Impairment of leukocyte function
D ) Increased fibrinogen production
E ) Increased microvascular vasoconstriction
The correct response is Option E.
The nicotine in cigarettes causes vasoconstriction of cutaneous blood vessels with resultant decreased tissue oxygenation. Smoking also increases carboxyhemoglobin, increases platelet aggregation, increases blood viscosity, decreases collagen deposition, and decreases prostacyclin formation, which all negatively affect wound healing. In addition, vasoconstriction associated with smoking is not a transient phenomenon. Smoking a single cigarette may cause cutaneous vasoconstriction for up to 90 minutes; hence, a patient who smokes one pack of cigarettes daily remains tissue hypoxic for most of each day. Vasoconstriction is mediated directly and indirectly by nicotine, a colorless, odorless, and poisonous alkaloid. A reduction in tissue perfusion results from elevated cellular levels of nicotine. The indirect pathways of vasoconstriction include the enhancement of thromboxane A2 and the stimulation of catecholamine release from the adrenal medulla, sympathetic ganglia and nerve endings, and cardiac chromaffin tissue. Other by-products, such as hydrogen cyanide, inhibit the enzymatic pathways vital for cellular oxidative metabolism and oxygen transport, effectively diminishing the ability for cellular repair and wound healing. Combined with acrolein, another toxic gaseous component, hydrogen cyanide inhibits leukocyte function, further impairing the inflammatory phase of healing. The proliferation of macrophages and fibroblasts, which are integral to the phases of wound healing, is also diminished by the presence of nicotine. Additionally, the presence of nicotine and catecholamines stimulates the production of chalones, which are hormones that retard and decrease the rate of wound epithelialization. Collagen deposition is also decreased in smokers. Nicotine is also associated with thrombogenesis by interfering with prostaglandin I2 (prostacyclin) activity. Prostaglandin I2 is a potent vasodilator and inhibitor of platelet aggregation. Platelet adhesiveness is augmented, raising the potential for thrombotic microvascular occlusion and subsequent tissue ischemia.
Carbon monoxide is another toxic by-product common in tobacco smoke. The oxygen-carrying capacity of blood is reduced by the competitive, inhibitory binding of carbon monoxide to hemoglobin. Carboxyhemoglobin levels rise, and tissue delivery of oxygen is reduced as the oxygen-hemoglobin saturation curve is shifted to the left. The decrease in oxygen available for tissue consumption leads to diminished wound healing. The resulting hypoxic state stimulates erythropoiesis, red blood cell aggregation, and fibrinogen production, leading to increased blood viscosity, which potentiates an environment already ripe for thrombogenesis. Decreased red blood cell deformability is also noted in smokers but through an unknown mechanism.
Which of the following is the most common cause of death following suction lipectomy?
(A) Abdominal perforation
(B) Anesthetic complications
(C) Fat embolism
(D) Infection
(E) Thromboembolism
The correct response is Option E.
The incidence of fatalities associated with suction lipectomy performed in the outpatient setting is one in every 5000 procedures. According to a recent study of deaths associated with suction lipectomy procedures, in those patients in whom a cause of death was definitively established, 23% of the fatalities were shown to have resulted from thromboembolism. In contrast, 15% of fatalities resulted from abdominal wall perforation (with or without organ perforation), 10% involved anesthetic complications, 8% involved fat embolism, and only 5% were due to infection. Because lidocaine screening is rarely performed, any potential link between lidocaine toxicity and the development of the complications listed above was undetermined. Many of the reported deaths occurred during the first 24 hours following patient discharge. Other risk factors associated with suction lipectomy include aspiration of large amounts of tissue, increased volume of tumescent injection, and concomitantly performed procedures.
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 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.
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.
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 32-year-old man is brought to the office 24 hours after he underwent liposuction of the upper extremities, breasts, and chest. He appears disoriented and confused. Examination shows a petechial rash over the anterior trunk and axilla. Which of the following is the most likely cause?
A) Allergic reaction to a medication
B) Fat embolism
C) Lidocaine toxicity
D) Thrombotic thrombocytopenic purpura
E) Transient ischemic attack
The correct response is Option B.
Fat embolization syndrome (FES) is clinically characterized by a triad of symptoms occurring within 24 to 72 hours following surgery or trauma: 1) alterations in mental status, 2) respiratory dysfunction, including hypoxemia or tachypnea, and 3) a petechial rash involving the anterior trunk, axillary, or head and neck regions.
Common predisposing conditions include traumatic long bone and pelvic fractures, orthopedic procedures, liposuction, and soft-tissue injuries. Non-traumatic etiologies include pancreatitis, diabetes mellitus, osteomyelitis, and alcoholic liver disease. Proposed mechanisms for fat embolism include 1) mechanical disruption—release of fat droplets from disrupted bone marrow or adipose tissue forced into torn venules in areas of trauma, or 2) biochemical—release of free fatty acids as chylomicrons induced by systemic changes from trauma or sepsis.
Diagnosis of FES is primarily clinical. Major diagnostic criteria include respiratory distress, cerebral dysfunction, and petechial rash. Minor criteria include tachycardia, tachypnea, fever, hypoxemia, thrombocytopenia, and hypocalcemia. Treatment for FES is primarily supportive. Respiratory support should focus on maintaining adequate tissue oxygenation and arterial saturation. Mechanical ventilation may be necessary. Hemodynamic and fluid resuscitation may be required. Use of corticosteroids remains controversial.
The triad of symptoms including the petechiae concentrated in the upper truncal region would be an unusual occurrence for an allergic medication reaction. Lidocaine toxicity occurs initially with perioral numbness, vertigo, and visual disturbances, and progresses to muscle twitching, unconsciousness, seizures, and finally to cardiorespiratory failure. Lidocaine toxicity would be earlier in onset and is not associated with a petechial rash. Although thrombotic thrombocytopenic purpura (TTP) may initially occur with petechiae, TTP is more commonly associated with headache, confusion, and digestive symptoms such as diarrhea, nausea, and abdominal pain. Transient ischemic attack may occur with temporary loss of vision, hemiparesis, confusion, or paresthesia.
A 29-year-old woman comes to the office for evaluation of upper arm fullness. Physical examination shows moderate excess subcutaneous fat and minimal skin laxity. Circumferential liposuction is planned. Which of the following is the most likely complication after liposuction of the bicipital groove region?
A) Compartment syndrome
B) Contour deformity
C) Paresthesia
D) Seroma
E) Skin necrosis
The correct response is Option B.
When performing suction lipoplasty of the upper arm, the medial portion around and below the area of the bicipital groove should be avoided. The fat layer in this area is very thin, and wrinkling and poor skin contraction may occur. The most common areas of liposuction of the upper arm include the posterior brachial and the lateral aspects. The treatment of the para-axillary region, the deltoid bulge, and the upper back were popularized in the 1980s and the 1990s and are still performed today.
A 48-year-old man comes to the office because he is dissatisfied with the appearance of his “enlarged” breasts. He underwent gastric bypass surgery 2 years ago followed by a 110-lb (50-kg) weight loss. Current weight is 185 lb (84 kg), which has been stable for 6 months. Physical examination shows nipples with an enlarged areola inferior to the inframammary fold, excess skin with loss of skin elasticity, and a moderate amount of fatty tissue. No palpable or painful masses are noted. Which of the following is the most appropriate surgical procedure for correction of this patient’s deformity?
A) Injection of phosphatidylcholine
B) Nonsurgical radiofrequency fat ablation
C) Reduction mammaplasty
D) Skin-sparing mastectomy
E) Ultrasound-assisted liposuction
The correct response is Option C.
This patient suffers from pseudogynecomastia, also known as lipomastia.
Reduction mammaplasty with repositioning the nipple at or above the inframammary fold, reduction of the size of the areola, removal of excess skin, and removal of excess fatty tissue will most appropriately correct this patient’s deformity. However, many insurance companies recognize this code as a gender-specific code for women. This patient’s concerns are primarily with appearance. Breast reduction should be performed as a cosmetic procedure.
No good controlled studies show the benefit of radiofrequency in the treatment of gynecomastia or pseudogynecomastia. The safety and efficacy of phosphatidylcholine injections have yet to be established. Liposuction will not address the skin problem or correct the enlarged areolae. Mastectomy for gynecomastia is a surgical procedure for the removal of painful, periareolar glandular tissue usually in pubescent males and is sometimes covered by insurance.
A 45-year-old woman comes to the office because of persistent dysesthesias of the medial forearm 2 months after she underwent brachioplasty for brachial ptosis. Examination shows a well-healed scar on the medial aspect of the arm extending to the proximal elbow. Which of the following nerves was most likely injured during the procedure?
A) Axillary
B) Medial antebrachial cutaneous
C) Median
D) Posterior interosseous
E) Ulnar
The correct response is Option B.
When performing brachioplasty, injury to the medial antebrachial cutaneous nerve can occur. This nerve runs along to the medial epicondyle and adjacent to the basilic vein. Maintaining superficial dissection at the ulnar aspect of the elbow and preserving the basilic vein is paramount in minimizing injury to the medial antebrachial cutaneous nerve.
Although theoretically possible, injury to the ulnar and median nerves has not been reported with brachioplasty. The axillary nerve and posterior interosseous nerve should not be in the field of dissection when performing a brachioplasty.
An otherwise healthy 34-year-old woman calls the office because of nonspecific left-sided chest pain and mild shortness of breath 2 weeks after she underwent abdominoplasty with plication of a rectus diastasis and liposuction of the flanks. The procedure was performed during general anesthesia in 3 hours and 15 minutes. She was admitted overnight, and heparin was administered subcutaneously during her hospital stay, including one dose preoperatively. She reports no postoperative complications and feels extremely well otherwise. She says she is “finally getting back to herself physically” and does not want to worry her husband or children. She just wanted to make sure she had not “pulled a muscle or injured anything.” Which of the following is the most appropriate action by the plastic surgeon?
A) Evaluation at the emergency department
B) Reassurance
C) Reduction of physical activity
D) Use of incentive spirometer at home to assist in improving pulmonary toilet
E) Use of over-the-counter anti-inflammatory drugs
The correct response is Option A.
This patient is likely suffering from a pulmonary embolism and requires emergent workup and treatment with anticoagulation. Although she was treated perioperatively with subcutaneous heparin, deep venous thrombosis (DVT) can still develop as well as a resultant pulmonary embolism (PE). In one survey of board-certified plastic surgeons, PE was found to be the leading cause of death following liposuction. In aesthetic plastic surgery patients, abdominoplasty patients appear to be at a higher risk of venous thromboembolism (VTE) when compared to those undergoing other commonly performed elective procedures. Rates range from 1 in 1000 to 1 in 300 for standard abdominoplasty, and when combined with other procedures, the risk of VTE and death from PE increases significantly. Any possible symptoms that are suspicious for PE, even several weeks postoperatively, must be taken very seriously and treated urgently with immediate presentation to the closest emergency department for aggressive and urgent medical workup as well as imaging and laboratory studies to evaluate for DVT and/or PE.
Venous thrombus formation occurs secondary to a triad of factors describes by Virchow: venous stasis, vascular injury, and hypercoagulability. During abdominoplasty, the combination of general anesthesia, supine positioning, and immobilization promotes venous stasis. In addition, decreased venous return prevents clearance of activated clotting factors, further leading to thrombus formation. The highest risk period for fatal postoperative PE occurs 3-7 days after surgery, with approximately 10% of symptomatic PE being fatal within 1 hour of first symptoms. The risk of symptomatic venous thromboembolism is highest within 2 weeks of surgery and remains elevated for 2 to 3 months. Two thirds of patients with a DVT may appear clinically silent making the need for thromboprophylaxis extremely important. Current strategies to reduce risk include proper patient positioning, early ambulation postoperatively, flexion of the patient’s knees 5 degrees, supplemented with mechanical (e.g., pneumatic compression boots) and/or pharmacological prophylaxis in most patients. The most common practice for pharmacological prophylaxis is to begin therapy preoperatively and continue treatment until 5 to 10 days after surgery. Some studies have even suggested a full month of postoperative treatment for those patients at a higher risk.
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 35-year-old man is scheduled to undergo a medial thigh lift. He underwent bariatric surgery 2 years ago and has lost 120 lb (54 kg). To decrease the risk of seroma formation, care must be taken to preserve the area defined by the inguinal ligament and which of the following additional structures?
A ) Adductor longus muscle and sartorius muscle
B ) Gracilis muscle and adductor magnus muscle
C ) Great saphenous vein and sartorius muscle
D ) Iliopsoas muscle and adductor magnus muscle
The correct response is Option A.
The incidence of seroma following medial thigh lift ranges from 4 to 20%, making it one of the most common complications of body contouring. It is critical to have an appreciation of the anatomical borders of the femoral triangle for two reasons. First, the concentration of lymphatics draining the lower extremity is very high within the femoral triangle. Second, direct injury to the inguinal lymphatic system often occurs inconspicuously, and so a preemptive approach should be taken to protect these structures.
The femoral triangle is bordered by the inguinal ligament, adductor longus muscle, and sartorius muscle. The iliopsoas muscle, pectineus muscle, inguinal lymph nodes, and femoral nerve, artery, and vein reside within the femoral triangle, as does the proximal portion of the great saphenous vein.
A 39-year-old woman is evaluated because she is dissatisfied with the appearance of her abdomen. She has had five pregnancies with two full-term deliveries and three second-trimester miscarriages. She takes no birth control pills. Physical examination shows wide diastasis with excess abdominal skin. BMI is 28 kg/m2. Abdominoplasty with translocation of the umbilicus is planned. This patient is at increased risk for which of the following complications?
A) Deep vein thrombosis
B) Hematoma
C) Infection
D) Recurrent diastasis
E) Wound dehiscence
The correct response is Option A.
A history of two late-term miscarriages stands out as a significant risk factor for thrombophilia (inherited and acquired) and subsequent deep vein thrombosis. It is imperative that these patients be identified and further evaluated. If abdominoplasty is performed, chemoprophylaxis is required. The most common inherited thrombophilia is factor V Leiden, which is present in 3 to 7% of the Caucasian population. Multiple inherited thrombophilic conditions can be present in the same individual. Studies have shown that complication rates in abdominoplasty increase in patients with a BMI greater than or equal to 30 kg/m2. Based upon history and physical examination alone, the other complications of hematoma, infection, recurrent diastasis, or wound dehiscence should not be significantly increased.
When performing a transverse thigh/buttock lift, which of the following operative techniques has been shown to decrease the frequency of complications, including widening and inferior migration of scars, traction deformity of the vulva, and early recurrence of thigh ptosis?
(A) Direct undermining of the distal flap
(B) Performing suction lipectomy in conjunction with transverse thigh/buttock lift
(C) Suspension of the superficial fascial system
(D) Use of an anterior medial skin resection pattern
The correct response is Option C.
Suspension of the superficial fascial system of the inferior skin flap has decreased the incidence of unfavorable scars, vulvar traction, and ptosis deformities previously associated with the transverse thigh/buttock lift. Anchoring the skin flap to Colles’ fascia anteriorly has lead to more consistent, reliable results following lifting. Other refinements such as direct undermining of the distal flap, performing adjunctive suction lipectomy, and using an anterior medial skin resection pattern have been associated with an improvement in overall results in those patients undergoing transverse thigh/buttock lifts but have not specifically decreased scar widening, traction deformities, and recurrent ptosis. Direct undermining, 3 to 4 cm beyond the planned line of resection, releases the superficial fascial attachments distally and allows for a greater lift. Suction lipectomy addresses fatty contour deformities that do not lie within the planned resection areas of the lift. The anterior medial skin resection pattern addresses skin laxity at the junction of the anterior and medial thigh and eliminates the need for incisions within the posterior buttock folds.
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 57-year-old woman is scheduled to undergo a medial thigh lift. Anchoring of the soft tissue of the medial thigh to the Colles fascia is planned. The Colles fascia is continuous with which of the following structures?
A ) Anococcygeal raphe
B ) Anterior rectus sheath
C ) Deep layer of the deep perineal fascia
D ) Posterior urogenital diaphragm
E ) Scarpa €™s fascia of the abdominal wall
The correct response is Option E.
Colles fascia was first described in 1811 as a fascial layer that helps to define the perineal-thigh crease. It is described as the deep layer of the superficial perineal fascia (not the deep perineal fascia) and lies deep to the subcutaneous fat of the perineum. Anteriorly, it is continuous with Scarpa €™s fascia of the abdominal wall. It is distinct, unrelated, and not continuous with the anterior rectus sheath. Posteriorly, Colles fascia fuses with the posterior border of the urogenital diaphragm. It does not occur posterior to this structure. The Colles fascia is high in elastin content, giving it a yellow hue which distinguishes it from nearby white muscular fascia.
Lockwood initially described the fascial anchoring technique to be employed at medial crescentic thigh lift at which the inferior thigh flap is anchored to this fascial layer with subdermal sutures to reduce the risk of inferior scar migration, labial spreading, and recurrent thigh ptosis.
For each patient, select the most appropriate management (A-E).
(A) Suction lipectomy
(B) Mini-abdominoplasty
(C) Full abdominoplasty
(D) Lower body lift
(E) Panniculectomy
1) A 35-year-old woman who has lost 150 lb following a gastric bypass procedure
2) A 45-year-old woman who weighs 400 lb and has a large, overhanging area of skin in the lower abdomen with ulceration
The correct response for Item 1 is Option D and for Item 2 is Option E.
In each of these patients who desires improved abdominal contour, the optimal procedure can be determined by evaluating the patient’s skin tone, abdominal wall musculature, and fat distribution.
The 35-year-old woman who had a massive reduction in weight following gastric bypass should undergo a lower body lift procedure. This will remove the excess skin and fat in the lower abdomen and thighs typically seen in patients who have lost an extensive amount of weight.
The obese 45-year-old woman who has a large, overhanging area of skin and fat (pannus) with ulceration should undergo panniculectomy. In this patient, gastric bypass may be performed either simultaneously or prior to the panniculectomy procedure.
Suction lipectomy alone is most appropriate for correction of localized abdominal protuberance in patients who have good skin tone and firm musculature in the abdominal wall. Mini-abdominoplasty is useful for removal of mild amounts of lower abdominal skin and fat. The length of the scar is limited with this procedure and the umbilicus is not altered. Full abdominoplasty removes the excess skin and fat in the lower abdomen but relocates the umbilicus and results in an elongated scar. This procedure does not correct excess skin in the flanks and upper thighs.
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.
A 43-year-old woman who recently lost 45.5 kg (100 lb) has severe skin laxity of the arms with moderate fat deposition. The most likely cause of her current findings is loosening of which of the following fascia?
(A) Clavipectoral
(B) Colles’
(C) Deltoid
(D) Pectoralis major
(E) Scarpa’s
The correct response is Option A.
This patient’s skin laxity is most likely caused by a loosening of the clavipectoral fascia. Anatomic studies have shown that in youth the soft tissues of the posteromedial arm are firmly suspended to a tough yet dynamic fascial system sling that ultimately gains its strength from the clavicular periosteum by means of the clavipectoral and axillary fasciae. The clavipectoral fascia lies deep to the pectoralis major muscle and extends from the clavicle to the dome of the axillary fascia. Loosening of these connections, combined with relaxation of the fascia itself with age, weight fluctuations, and gravitational pull, results in significant ptosis of the posteromedial arm. Other mechanisms contributing to arm ptosis include relaxation and stretching of the skin and superficial fascial system of the arm, as well as flaccidity of the posterior arm muscles resulting from age and lack of exercise. Fascial anchoring brachioplasty is used to correct this deformity.
Fascial anchoring and suspension of the superficial fascial system can be used in body contouring of other sites in the trunk and extremities, including Colles’ fascia in the medial thigh lift and Scarpa’s fascia in abdominoplasty. The deltoid and pectoralis major fascia have no effect on upper arm laxity.
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.
Suction lipectomy is an effective procedure for management for each of the following conditions EXCEPT
(A) axillary hyperhidrosis
(B) HIV-associated lipodystrophy
(C) liposarcoma
(D) lymphedema
(E) Madelung’s disease
The correct response is Option C.
Suction lipectomy is recommended for many conditions because it effectively removes tissue while limiting incisions. Indications for suction lipectomy include axillary hyperhidrosis, in which apocrine and eccrine glands are removed from the axilla using a superficial technique. This results in reduced sweating with a minimal amount of scarring. Although repeat procedures are necessary in approximately 30% of patients, suction lipectomy produces longer lasting effects than treatment with botulinum toxin (Botox).
In patients with HIV infection, administration of protease inhibitor agents may cause abnormal redistribution of fat. Affected patients may develop adiposity in the abdominal and mandibular regions and atrophy in other areas, such as the nasolabial fold. Suction lipectomy is appropriate to remove the excess fat.
Madelung’s disease, or benign symmetric lipomatosis, is a disorder of unknown cause that is characterized by diffuse growth of nonencapsulated lipomas, especially in the neck, shoulders, and posterior trunk. Suction lipectomy can increase range of motion and provide good cosmesis.
Patients with both congenital and acquired lymphedema can benefit from suction lipectomy to decrease tissue thickness. Although its effects are temporary, it provides significant relief and increases function. Other measures, such as massage and use of compressive garments, can be performed in combination with the lipectomy procedure.
Suction lipectomy is not recommended for removal of malignant tumors, such as liposarcoma, because this method of resection is often incomplete. In addition, such tumors may be seeded and histopathologic examination of the tumor specimen may be compromised.
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
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 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.
A 40-year-old woman says she has a burning pain in the thigh with movement the day after undergoing abdominoplasty. Which of the following nerves was most likely injured during the procedure?
A) Genitofemoral
B) Iliohypogastric
C) Ilioinguinal
D) Lateral femoral cutaneous
E) Saphenous
The correct response is Option D.
In several studies of complications of abdominoplasty, the most common nerve injury was to the lateral femoral cutaneous nerve. Symptoms include anterior and lateral thigh burning, tingling, and/or numbness, all of which increase with standing, walking, or hip extension. Injury or entrapment of the lateral femoral cutaneous nerve is also known as meralgia paresthetica.
The genitofemoral nerve supplies the proximal portion of the thigh about the femoral triangle just lateral to the skin that is innervated by the ilioinguinal nerve. Nerve injury may result from hernia repair, but injury to this nerve is rare.
The iliohypogastric nerve arises primarily from L1. The distribution of the cutaneous sensation of the iliohypogastric nerve is most commonly a small region just superior to the pubis. The iliohypogastric nerve is rarely injured in isolation. Symptoms include burning pain into the inguinal and suprapubic region.
The ilioinguinal nerve arises from the fusion of the T12 and L1 nerve roots and pierces the transversus abdominis and internal oblique muscles. The nerve then supplies sensory branches to the pubic symphysis, the superior and medial aspect of the femoral triangle, and either the root of the penis and anterior scrotum in men or the mons pubis and labia majora in women. The nerve can be injured in abdominoplasty and other lower abdominal incisions. Symptoms include paresthesia of the skin along the inguinal ligament. The sensation may radiate to the lower abdomen. Pain may be localized to the medial groin, the labia majora or scrotum, and the inner thigh.
Saphenous nerve symptoms of entrapment may include a deep aching sensation in the thigh, knee pain, and paresthesias in the cutaneous distribution of the nerve in the leg and foot.
A 43-year-old woman is scheduled to undergo mastopexy and circumferential lower body lift in an accredited hospital setting for body contouring. She lost 150 lbs (68 kg) after undergoing bariatric surgery 3 years ago. The planned duration of the procedure is 6 hours. In the preoperative holding room, she is dressed in an air-heated gown. Maintenance of normothermia during the perioperative period is most likely to decrease the risk of which of the following complications in this patient?
A)Deep venous thrombosis
B)Fat necrosis
C)Pulmonary embolism
D)Seroma formation
E)Surgical site infection
The correct response is Option E.
There is a significant and growing body of evidence showing that normal body temperature during surgery specifically reduces the likelihood of surgical site infections and reduces the risk of bleeding. For this patient with a long operative time and exposure of a significant amount of body surface area, she is at increased risk for hypothermia and surgical site infection.
Fat necrosis is attributable to devascularization of fatty tissue. Seroma formation is attributable to inadequate drainage of the surgical wounds.
The likelihood of deep venous thrombosis and pulmonary embolus is reduced by the use of subcutaneous heparin, low-molecular-weight heparin, and/or sequential compression devices.
A 32-year-old woman who smokes two packs of cigarettes daily wishes to undergo full abdominoplasty to correct excess skin and fat in the lower abdomen resulting from two pregnancies. The risk for development of complications in this patient is closest to
(A) 10%
(B) 30%
(C) 50%
(D) 70%
(E) 90%
The correct response is Option C.
Because conventional abdominoplasty procedures involve significant undermining, there is increased potential for complications, such as skin necrosis, infection, wound dehiscence, seroma, and hematoma. In addition, plastic surgery procedures are associated with a high incidence of adverse effects when performed in patients who smoke. These complications are related to the release of nicotine and carbon monoxide during smoking, which decrease blood flow and oxygen delivery and induces thrombogenesis. There is dysfunction of leukocytes, macrophages, and fibroblasts, leading to impaired wound healing.
One recent study of 132 patients who underwent abdominoplasty reported a complication rate of 48% in smokers, compared with a complication rate of 15% in those patients who did not smoke. Another study of 199 abdominoplasty patients reported a complication rate of 52% in smokers and 24% in nonsmokers.
Patients should be advised to discontinue smoking four to eight weeks before the surgical procedure and for an additional four weeks after surgery. Serum levels of nicotine have been shown to return to normal when patients abstain from smoking for eight weeks. In addition, studies of patients who underwent flap reconstruction showed that complications were decreased significantly when smoking was discontinued a minimum of four weeks before surgery.
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 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 36-year-old woman has numbness of the anterolateral right thigh one month after undergoing abdominoplasty. The most likely cause is injury to which of the following nerves?
(A) Genitofemoral
(B) Lateral cutaneous
(C) Iliohypogastric
(D) Ilioinguinal
(E) Obturator
The correct response is Option B.
In this 36-year-old woman who has numbness of the anterolateral right thigh one month after undergoing blepharoplasty, the lateral cutaneous nerve of the thigh is most likely injured. This nerve arises from L2-3 and passes through the inguinal ligament approximately 1 cm medial to the anterosuperior iliac spine. It then passes superficially to the sartorius muscle and divides into anterior and posterior branches in the thigh. The anterior branch becomes superficial about 10 cm below the anterosuperior iliac spine, supplying sensation to the skin of the anterior and lateral thigh. Injury is likely to result in numbness and dysesthesia in this region.
According to the results of a recent study of 101 abdominoplasty patients, 10% had symptoms consistent with injury to the lateral cutaneous nerve. Other studies have reported rates of lateral cutaneous nerve injury following abdominoplasty ranging from 10% to 32%. It is important that the surgeon use extreme caution when performing lateral dissection during this procedure.
The genitofemoral nerve originates from L1-2 and inserts into the abdomen at a variable distance above the inguinal ligament. This nerve divides into genital and femoral branches; the genital branch supplies sensation to the skin of the scrotum, mons pubis, or labia; the femoral branch supplies sensation to the skin over the upper part of the femoral triangle.
The iliohypogastric nerve arises from L1 and divides into lateral and anterior branches. The lateral branch provides sensation to the skin of the lateral part of the buttocks, and the anterior branch supplies sensation to the skin of the abdomen above the pubis.
The ilioinguinal nerve originates from L1 and passes through the superficial inguinal ring to supply sensation to the skin of the superomedial portion of the thigh and the scrotum or mons pubis.
The obturator nerve arises from L2-4 and courses through the lower pelvis with the obturator vessels. It then enters the thigh to provide sensation to the skin of the medial and lower thigh.
Which of the following subcutaneous infiltration techniques used in a patient undergoing suction lipectomy has an infiltrate-to-aspirate ratio of 1:1?
(A) Dry
(B) Superwet
(C) Tumescent
(D) Wet
The correct response is Option B.
The superwet technique was first used for subcutaneous infiltration in the late 1980s. This technique involves the injection of a diluted solution of anesthesia and vasopressors that is of equal volume to the estimated volume of fat removed, or an infiltrate-to-aspirate ratio of 1:1. Blood loss in this technique has been shown to vary from 1% to 4% of the aspirate.
In the dry technique, local anesthetics and epinephrine are not injected.
The tumescent technique involves the injection of 2 to 3 mL of wetting solution for every 1 mL of aspirate. One study of 112 patients who had undergone suction lipectomy reported injection, on average, of 4,600 mL of anesthetic solution and an average removal of 2,657 mL of aspirate. Pumps were used to infiltrate the solution at a rate of 50 to 200 mL/min, depending on the affected region of the body and tolerance of the patient. Blood loss of less 1% was noted in these patients, and virtually all procedures were performed using local anesthesia.
With the wet technique, 100 to 300 mL of fluid is injected into each treatment area regardless of the amount of aspirate removed. However, this technique has been shown to result in extensive bruising when performed using general anesthesia, and blood loss has been shown to be as high as 25%.
A 40-year-old woman comes to the office for follow-up examination three weeks after undergoing traditional brachioplasty for correction of skin laxity in the proximal aspect of the upper arms. She has had persistent numbness along the medial aspect of the elbow and forearm, extending to the level of the wrist. Which of the following nerves was most likely injured during brachioplasty in this patient?
(A) Intercostobrachial
(B) Medial antebrachial cutaneous
(C) Medial brachial cutaneous
(D) Musculocutaneous
(E) Posterior brachial cutaneous
The correct response is Option B.
Traditional methods of brachioplasty use a medial or posteromedial longitudinal incision to resect excess skin and fat. The medial antebrachial cutaneous nerve branches, together with the basilic vein, exit the deep fascia of the medial arm at the transition between the middle and distal thirds of the arm. Care should be taken at the time of surgery to identify this nerve at this level and maintain more fat on the deep fascia to prevent injury.
The intercostobrachial nerve and the medial brachial cutaneous nerve innervate the medial arm skin. The musculocutaneous nerve terminates in the lateral antebrachial cutaneous nerve, supplying sensation to the lateral forearm. The posterior brachial cutaneous nerve, a branch of the radial nerve, supplies sensation to the posterior arm.
A 42-year-old woman is undergoing brachioplasty after a massive weight loss. The surgeon is most likely to avoid injury to the medial antebrachial cutaneous nerve during the procedure if he or she is able to identify it in the elbow at which of the following locations?
A) Deep to the deep fascia traveling with the basilic vein
B) Deep to the deep fascia traveling with the cephalic vein
C) Superficial to the deep fascia traveling with the basilic vein
D) Superficial to the deep fascia traveling with the cephalic vein
The correct response is Option C.
The position of the medial antebrachial cutaneous nerve (MABC) makes it vulnerable to injury during a brachioplasty. Understanding its course and relationship to other structures allows the surgeon to identify and protect it. The MABC is a sensory nerve. It is a terminal branch of the medial cord of the brachial plexus. It travels with the basilic vein medial to the biceps brachii muscle, and it pierces the fascia at the basilic hiatus proximal to the elbow. Injury to the MABC can cause areas of numbness of the median forearm, as well as painful neuromas. The MABC is best identified in the distal aspect of the brachioplasty incision with the basilic vein and protected during the dissection.
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.
Following abdominoplasty, skin necrosis is most likely to occur at which of the following sites?
(A) Epigastrium
(B) Flanks
(C) Periumbilical region
(D) Suprapubic region
(E) Umbilicus
The correct response is Option D.
Following abdominoplasty, skin necrosis is most likely to occur in the suprapubic region. The blood supply to the abdominoplasty is derived from the lateral interstitial vessels; because of this, the lower midline region of the flap is most at risk for devascularization. In addition, downward transposition of any pre-existing scars on the upper abdomen will limit blood flow and ultimately inhibit flap vascularization.
Because the epigastrium and flanks are in close proximity to the base of the elevated skin flap, they are better protected and at less risk for development of necrosis. Although umbilical necrosis is rare, it can occur as a result of excessive defatting of the umbilical stalk, tension during attachment to the abdominal skin, or compression of the stalk during plication of the rectus.
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 36-year-old woman is scheduled to undergo a circumferential body lift procedure for correction of skin laxity resulting from a 100-lb weight loss. After the preoperative consultation, a simultaneous procedure to correct the flat and unnatural appearance of the patient €™s buttocks is planned. Which of the following is the most appropriate method of buttock augmentation for this patient?
(A) Autologous gluteal flaps
(B) Autologous fat injections
(C) Silicone gel prostheses
(D) Solid silicone prostheses
The correct response is Option A.
Autologous gluteal flaps provide easily accessible donor tissue that can be used simultaneously in body lift procedures. The dermal fat flaps can be elevated safely to autoaugment the buttocks. This technique adds no more than 45 minutes to the procedure and does not add to the usual complications of body lift procedures in general.
Autologous fat transfer can be used to enhance buttock shape, but unfortunately the buttocks of many of these patients are deflated and do not have adequate donor sites for grafting. Free tissue transfers are not recommended for buttock augmentation. Silicone prostheses, both solid and gel types, are associated with less than optimal outcomes because of palpability and a greater risk of infection and dehiscence.
Augmentation with fat injections from liposuction is possible, but the results are less predictable than the use of vascularized tissue.
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 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.
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 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.
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.
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.
