Brachioplasty and Upper Trunk Contouring Flashcards
Brachioplasty The most common technique leaves a visible scar along the inner aspect
of the arm
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Upper body contouring includes removal ofan axillary roll
and back skin to tighten the entire upper torso. This is commonly known as a bra-line lift and may be combined with
breast and arm contouring
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The maximum body mass index
(BMI) prior to weight loss should be recorded along with the current BMI. Higher BMI at both time points has been associated with
higher complication rates after surgery
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Timing ofbody contouring
procedures should allow at least 12 months after bariatric surgery
and 6 months at a stable weight for patients to achieve metabolic and
nutritional homeostasis.
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No amount of physical exercise will correct
an excess of loose skin
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Classification schemes are not widely used in clinical practice;
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Teimourian and Malekzadeh in 1998, divided upper
arm findings into four categories
■ Group 1: Patients with minimal to moderate subcutaneous fat and
minimal skin laxity
■ Group 2: Patients with generalized accumulation ofsubcutaneous
fat and moderate skin laxity. The authors suggested management
of these patients with liposuction, with the possible addition of a
small axillary skin excision
■ Group 3: Patients with excess fat and extensive skin laxity requiring combined liposuction and direct soft-tissue excision
■ Group 4: Patients with minimal excess adiposity but significant skin laxity, requiring brachioplasty without adjunctive
liposuction
Appelt et al. in 2006 added the variable of location of
skin excess
■ Type I: Patients with relative excess ofadipose tissue but good skin
quality and tone, for whom liposuction alone was recommended
■ Type II: Patients with minimal to moderate adipose tissue and
moderate skin laxity. Excisional brachioplasty techniques were
endorsed for this patient population, with a further subdivision
into type IIA, IIB, and IIC based on the location ofskin excess and
the related skin excision pattern
■ Type III: Patients with both significant lipodystrophy and redundant skin laxity fall into three categories:
o Continued weight loss prior to surgery
o Staged treatment with initial liposuction followed by excisional brachioplasty
o Combined liposuction-excisional brachioplasty
The superficial fascia! system is found between the superficial and deep layers ofsubcutaneous fat
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some authors advocate plication of The superficial fascia! system during
the closing portion of the procedure
Loosening of this layer with
age or significant weight fluctuations can contribute to upper arm
ptosis
The deep fascia! system envelops the musculature, and all major neurovascular structures of the
arm lie deep to this layer. Care should be taken to avoid violation of
this layer during all aspects of the procedure
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Two sensory nerves travel superficial to the deep fascia! layer and
are thus at risk during brachioplasty procedures
the medial brachia!
cutaneous nerve and the medial antebrachial cutaneous (MABC)
nerve
Both nerves arise from the medial cord of the brachia! plexus
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Wich of these nerve more frequently involved
Medial antebrachial cutaneous nerve
MABC is more frequently involved of the two,
pierces the deep fascia an average of 14 cm proximal to the medial
epicondyle
T. MABC is more frequently involved of the two,
pierces the deep fascia an average of 14 cm proximal to the medial
epicondyle and travels with the basilic vein in the superficial plane of
the distal half to third of the upper arm
hoe we can prevent damage to this nerve
To prevent damage to these
sensory nerves, at least 1 cm offat should be left on the deep brachia!
fascia ofthe upper arm if possible
Adjunctive liposuction can also be
employed to facilitate atraumatic dissection and lymphatic preservation of lymphatics to decrease seroma formation
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full
motor and sensory examinations of the bilateral upper extremities,
in addition to assessment of skin quality and tone
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For patients with minimal skin laxity and a mild to moderate amount
of adipose deposits in the upper extremity, liposuction can be performed as a stand-alone technique for upper extremity recontouring
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leaving a layer of fat above the deep brachia! fascia
to preserve lymphatics and avoid significant contour irregularities
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Liposuction to the bicipital groove is avoided, WHY ?
to minimize contour irregularity in this region, which is known anatomically to be relatively devoid of fat
For patients with good skin quality but a moderate excess of skin and
adipose tissue limited to the proximal one-half to one-third of the
upper arm what type of intervention you will employ
Minibrachioplasty (Limited Medial Incision
Brachioplasty)
the minibrachioplasty is a reasonable option to consider.
This procedure has little to no benefit for the MWL patient
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the witch of flap in minibrachioplasty which is generally
limited to 3 to 5 cm at its widest point
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The axillary elliptical incisions are made using a
scalpel, and then electrocautery is used to raise the tissue in a subcutaneous plane.
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No need to undermine the medial and lateral flap for closure in minbrachioplasty
T The medial and lateral skin flaps may be undermined
to facilitate closure, but this is typically not necessary
Most MWL patients require extended brachioplasty
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a vertical dart (dashed
lines) for dog-ear removal or to excise more redundant upper arm skin.
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An
extension to the chest wall is often added and is known as an
L-brachioplasty along the postrerior axillary line
F with the superior L-point in or near the deltopectoral groove along the anterior axillary line
The amount of tumescent fluid should be minimized,
so as to avoid large-volume swelling that may ultimately inhibit the
degree of resection
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Liposuction can be don
beyond the borders of the planned resection
F Liposuction
beyond the borders of the planned resection is intentionally limited, as aggressive liposuction of these areas may compromise the
remaining soft tissue and lead to postprocedure skin loosening when
swelling resolves
Reapproximation of the superficial fascia! system importantly helps maintain contour and prevents scar
puckering
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Liposuction facilitates the dissection plane and leaves fat down on the deep fascia, thus helping to preserve
nerves and lymphatics
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Recent studies have demonstrated intact sensory and lymphatic
function following brachioplasty employing liposuction for atraumatic dissection of tissue planes
T This technique helps preserve
the layer of fat above the deep brachia! fascia harboring the sensory
nerves and lymphatics.
Risk factors
that may increase the chance of overall complications, hematoma,
or infection include»»>
male gender, BMI >30, and combined procedures.
An anterior scar placed just below the bicipital groove of the upper arm is
well hidden on both anterior and posterior views
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If the incision is instead placed posteriorly, it will be visible
when the patient has his or her arm by the side, but it may have the
advantage of avoiding the arm sensory nerves with tissue removal.
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The medial and lateral borders of the breast are defined by the sternocostal junction and the midaxillary line,
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The fourth intercostal space marks the superior boundary. The inframammary fold (IMF) delineates the inferior border of the breast
F The second
intercostal space marks the superior boundary. The inframammary
fold (IMF) delineates the inferior border of the breast
The inframammary
fold (IMF) formed
by the fusion of the deep and superficial fascia with the dermis
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Layers of deep and superficial fascia support the soft tissues of the
breast, as do the suspensory Cooper ligaments
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The subdermal plexus provides blood supply to the skin and nipple-areolar complex (NAC)
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Blood supply to the breast
branches of the internal mammary artery, the lateral thoracic artery, the thoracodorsal
and thoracoacromial arteries, and multiple intercostal perforators
Innervation of the breast is derived from anteromedial and
anterolateral branches of the thoracic intercostal nerves, with the
fourth intercostal nerve considered the major contributor to the
NAC.
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Lymph node drainage of the breast
The subareolar and subdermal regions drain via the superficial lymphatic system to the axillary basin. The deep lymphatic
system drains to the axillary nodes as well, but also exhibits connections with a perforating system that drains to the internal mammary
nodes. Other node fields that directly drain the breast include the
interpectoral, infraclavicular, supraclavicular, and intercostal nodal
basins
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nipple position in MWL patients is frequently located too medial and
the IMF too inferior compared with normal breast anatomy,
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Breast ptosis
is nearly universal in the weight loss population.
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For the patient desiring an increase in breast size, a breast
augmentation alone enough to correct the loose skin and pto·
sis.
F For the patient desiring an increase in breast size, a breast
augmentation alone rarely is enough to correct the loose skin and pto·
sis.
history of personal or
family breast cancer, prior breast procedures, and up-to-date mam·
mography results must be obtained somtimes
F history of personal or
family breast cancer, prior breast procedures, and up-to-date mam·
mography results must be obtained as part ofthe preoperative workup
The safest technique for breast reduction in MWL is superior-based pedicles
F Although all breast reduction techniques may be considered, the superior safety profile of the inferior pedicle should be taken into account, given the lengthy sternal notch-to-nipple distance typical of weight loss
patients. A Wise skin pattern is most commonly chosen to reduce the
large skin excess
Skin flaps are then raised approximately 1.5 cm in thickness in inferior base flap
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The inferior pedicle is plicated, leaving 10 cm between the base of the areola and the IMF.
F The inferior pedicle is plicated, leaving 5 to 5.5 cm between the base of the areola
and the IMF.
Medial, lateral, and superior sections are then tacked to the
pectoralis fascia or rib periosteum
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If the degree of excess skin and ptosis is less severe, a vertical/
extended vertical mastopexy with preservation and advancement of
the inferior pole tissues can be considered
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Autologous Autoaugmentation advantage ?
taking advantage of excess axillary and posterior
trunk tissue to provide increased superior pole volume
improved lateral breast definition, and correction of axillary/back irregularities.
mastopexy with autologous auto augmentation using wich flap?
an intercostal artery perforator (ICAP) flap/spiral flap
Doppler probe is used to confirm the perforator location posterior to the anterior axillary line
F anterior to the anterior axillary line
The flaps are raised from posterior to anterior in the subfascial plane. To obtain adequate rotation of
the flap for inset
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perforating vessels from the thoracodorsal system
should be preserved
perforating vessels from the thoracodorsal system
must be sacrificed.
the mobilized ICAP flap is rotated around the
inferior pedicle and secured to the chest wall medially, superiorly,
and laterally
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Inadequate mobilization leads to a boxy breast with lateral fullness. Failure to preserve the intercostal arteries leads to fat necrosis
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For patients who desire more superior fullness, mastopexy with
implants is recommended in one or two stages
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we can choose the size that the patients desired in this case
F Owing to the thin,
overstretched skin typical of MWL patients, patients are advised to
choose a conservative implant size, and two stages may be considered
for more predictable results.
In one-stage augmentation mastopexy, the implant pocket is
approached through a vertical or IMF incision by preserving the
superior and medial blood supplies to the breast
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The implant is placed
subpectorally only?
F The implant is placed
subpectorally in a dual plane or in a subglandular position
In two-stage augmentation mastopexy, the mastopexy is performed first followed by the augmentation procedure 3 to 6 months
later.
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In the case of two stage the implant can be out through the tradisional IMF fold?
care is taken to make a lateral IMF incision for implant
placement. If instead the superior/medial blood supply was preserved for the breast lift, the vertical incision may be used to place
the implant.
axillary and back roll excision can be achieved via posterior midback/bra-line lift.
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This procedure can be performed in conjunction with breast contouring or may be added as a second stage
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There are theoretical concerns about opposing vectors if performed at the same time so how we can do both surgery together
however, both procedures rely primarily
on lifting of the inferior tissues superiorly, so they may be performed
together safely and effectively in experienced hands
Evaluation of the degree of excess skin and adipose tissue forms the
basis for operative planning
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the Pittsburgh Weight Loss Deformity Scale
■ Grade 0: Normal contour of the back
■ Grade 1: Excess adiposity or a single fat roll
■ Grade 2: Multiple skin and fat rolls
■ Grade 3: Ptosis of the fat rolls
the ideal placement of the final
scar should be set at the level of the planned IMF. or bra strap borders
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The superior incision is designed immediately above the planned final scar; the lower
incision can be expected to elevate significantly during closure and
is based on a pinch test
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The extent of the incision
The incisions extend from the lateral IMF,
along the lateral chest wall, to the posterior chest
Severe deformities will require a scar that crosses the midline avoid a dog-ear
for less severe deformity, the central skin
of the back is preserved and bilateral wedge excisions are performed.
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The superior incision is made and carried down through
Scarpa fascia using electrocautery
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Bra-line lift. The excess tissue ofthe back is removed at a level
just below Scarpa fascia.
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The most common complication reported with this procedure is hematoma
F The most common complication reported with this procedure is the widening of the scar
Upper body contouring procedures are not associated
with excessive amounts of blood loss. Therefore, an upper body lift
including brachioplasty, excision of axillary and back rolls/bra-line
lift, and breast contouring can be combined into one operative procedure in many patients
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combine one or more surgical procedures
into one operative setting depends upon the age, health, and desire
of the patient as well as planned operative time and experience of
the surgeon
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Upper body contouring can also be combined
with lower body contouring procedures
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a total body lift is
typically avoided secondary to excessive operative time, blood loss,
and morbidity.
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a vertical dart (dashed
lines) for dog-ear removal or to excise more redundant upper arm skin.
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if they desire improved arm contour. The superior incision is
marked approximately one fingerbreadth above the bicipital
groove
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Three-layer closure of the wound
is also performed using absorbable sutures in a sequential fashion,
over a drain in brachioplasty
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The breast technique employed largely depends on the current
breast volume and desired breast volume
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The shaped pedicle resembles the appearance ofan implant;
however, it descends more than an implant with healing, resulting in less sustained upper pole fullness.
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circumvertical or Wise-pattern mastopexy is then tailor-tacked around
the implant In one-stage augmentation mastopexy,
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