Body Contouring Flashcards
How do you define massive weight loss
100% of Ideal bW loss of 100lbs
What are options for bariatric surgery
- MALABSORPTIVE
- JI bypass - historical - loss of SB
- RESTRICTIVE
- Gastric banding
- Vertical band gastroplasty (stapled)
- Adjustable band
- Sleeve gastrectomy
- Intra-gastric balloon
- Gastric banding
- BOTH
- Bastric bypass (Roux en Y)
- Sleeve gastrectomy + Duodenal switch
What are points on Hx and PE for Massive weight loss patient?
HISTORY
-
Weight
- How, when, how much, fluctuations, min/max
- Compx w bariatric surgery
-
Activity level/Diet
- current wt, exercise, diet, protein amnt, suppl.
-
PMHx
- GERD, CAD/CVD, HTN, anemia, ObSA
- VTE risk
- Other surgeries
- Smoking
-
Patient expectations
- discuss goals
- planned pregnancies
- Screen for BMD/SIMON
PHYSICAL EXAM
-
General
- wt, ht, BMI, body habitus
- vitals
- hair/mucous membranes
-
Skin
- quality, striae, scars, deflation, atrophy
-
Fat distribution
- lipodystrophy, intra/extraperitoneal, volume
- Abdomen
- hernia/diastasis
- Lower extremtiies
- lymphedema
- varicose veins
What are contraindications to body contouring in MWL patient
- Absolute
- medically unfit to undergo GA
- Relative
- smoker
- BMI>35, CVD/renal/wound healing
- active intertrigo
- Specific
- no dermolipectomy of trunk if expected pregnancies
What investigations would you order pre-op
- Anesthesia consult, +/- Internist, Hematology (if VTE Hx), Dietician (if required)
- B/W: CBC, Fe, lytes, Cr, Urea,Alb, pre-alb, total Protein
- ECG, CXR
What are recommendations regarding intra-operative safe practices for body contouring for MWL
-
Staging procedures
- Want max 5-6hrs, EBL<500, no contradicting vectors
- Stage 1- Lower body (abdo,lower body lift) + Upper body (Mastopexy+brachioplasty)
- Stage 2 - Medial thigh lift + other Upper body
- Stage 3 - Rhytidectomy
-
Markings
- Mark standing - confirm intra-op ALWAYS
-
Positioning
- careful padding!!!!!!! and positioning of limbs
-
Antibiotics
- pre-op + redose + post-op if drains
-
VTE prophylaxis
- early ambulation, SCD+TEDS
- LMWH controversial - postop
- Normothermia
- IV fluids
- Drains
-
Hospital vs Ambulatory: Admission
- if >6h, EBL>500, lipoaspirate >5L - do in hospital sentting, admit o/n
What are options for body contouring procedures
-
Lower Body
- Dermatolipectomy (mini/full abdominoplasty/panniculectomy)
- Lower body lift +/- flank excsion+/- buttock augmentation
-
Upper body
- Mastopexy, Augmentation, Reduction
- Lateral chest, upper back lipectomy
-
Upper extremity
- brachioplasty
-
Lower extremity
- Thighplasty - vertical or transverse scar
-
Face
- Rhytidectomy
What are features of an aesthetically pleasing umbilicus
- superior hooding
- inferior retraction
- ellipse/round
- shallow
Describe the vascular supply to the abdominoplasty flap
- Zone 1 - Central - xiphoid to level of ASIS between he two recti muscles =>superior and inferior deep epigastric arteries
- Zone 2 - Inferior - level of ASIS to pubic and inguinal creases =>superficial epigastric, deep epigastric, superficial external pudendal, superficial and deep circumflex
- Zone 3 - Lateral - lateral to recti muscles, flanks =>lower 6 thoracic intercostals and 4 lumber inercostal (posterior and lateral branches)
Describe options for dermolipectomy of abdomen
- Miniabdominoplasty - infraumbilical dissection and plication with short scar (12-16cm)
- Traditional abdomnioplasty
- ensure incision kept parallel to mons , then above and parallel to inguinal creases and determinates inferolateral to ASIS to prevent scar show
- Fleur-de-lis
- horizontal and vertical dermolipectomy - each marked separately - with H as per usual and V with mark down midline then ellipse using pinch
- Lockwood’s high lateral tension abdomnioplasty
- reverse abdominoplasty
- address upper abdominal excess
- Circumferrential abdomnioplasty
- Umbilicoplasty
- floating
- diamond/rectangular shaped, inverted V, Vshaped,
- excise fat plug and suture down to abdo wall
List Lower Body Lift procedures and important considerations in operative planning
- Belt lipectomy
- circumferential torsoplasty, torsoplasty + buttock/thigh lift
- Lockwoods lower body lift type 1 => correction of buttock and lateral thigh with scar in groin crease
- upper incision will migrate inferiorly FAR less than the inferior incision which is marked low on the thigh to lift the inferior tissue
- Lockwoods lower body lift type 2: as above + abdominoplasty
- Rubin modification with inferior circumferetnail resection with autoaugmentation of buttock
- Autologous Gluteal Augmentation (AGA)may occur as island or moustache flap flipped over medially to recruit transverse tissue from trochanteric
PLANNING
- marking/scar placement
- positioning
- liposuctioning
- bttck augmentation
- mons reduction
- umbilicoplasty
List complications of body contouring
EARLY
- seroma
- wound dehiscence/delayed healing
- hematoma
- infection
- fat/skin necrosis
- stitcha abscess
- VTE
- perforated viscus
LATE
- scars - poor, visible
- asymmtries/irregularities
- umbilical distortion/scarring
- Hyperestesia/hypoesthesia
What is colles fascia
fascial system connecting the ischiopubic rami, scarpas fascia of abdomen and posterior border of urogenital
Describe your markings for thigh lift and procedure
Tranverse incision
- Superior incision: 4cm lateral to midline of mons, follows along inguinal crease until postior (gluteal) crease is reached
- Inferior incision - pinch to see how much meet superior incision.
Vertical incision
- along adductor tendon then posterior marking is done w pinch test
- curve away from patella as you approach
Always do belt lipectomy if required first
Incision Anterior superior first
Remain superficial above adductor magnus to avoid lympatics but can be deep in distal adductor
Segmental resection
Ensure SFS is supended - want to anchor to Colles
What are Indications and contraindications for brachioplasty
INDICATIONS
- deflation and skin laxity of arms - W extends beyond elbow, men etends to elbow only
- acceptable of visible scars and patience in scar maturation
CONTRAINDICATIONS
- ALND/RTX to axilla
- UE lymphadenopathy
- axillary hidradenitis
- signficant adiposity relative to skin laxity
