Brachioplasty and Upper Trunk Contouring

Question 1

Brachioplasty The most common technique leaves a visible scar along the inner aspect
of the arm

Answer 1

T

Question 2

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

Answer 2

T

Question 3

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

Answer 3

T

Question 4

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.

Answer 4

T

Question 5

No amount of physical exercise will correct
an excess of loose skin

Answer 5

T

Question 6

Classification schemes are not widely used in clinical practice;

Answer 6

T

Question 7

Teimourian and Malekzadeh in 1998, divided upper
arm findings into four categories

Answer 7

■ 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

Question 8

Appelt et al. in 2006 added the variable of location of
skin excess

Answer 8

■ 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

Question 9

The superficial fascia! system is found between the superficial and deep layers ofsubcutaneous fat

Answer 9

T

Question 10

some authors advocate plication of The superficial fascia! system during
the closing portion of the procedure

Answer 10

Loosening of this layer with
age or significant weight fluctuations can contribute to upper arm
ptosis

Question 11

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

Answer 11

T

Question 12

Two sensory nerves travel superficial to the deep fascia! layer and
are thus at risk during brachioplasty procedures

Answer 12

the medial brachia!
cutaneous nerve and the medial antebrachial cutaneous (MABC)
nerve

Question 13

Both nerves arise from the medial cord of the brachia! plexus

Answer 13

T

Question 14

Wich of these nerve more frequently involved

Answer 14

Medial antebrachial cutaneous nerve

Question 15

MABC is more frequently involved of the two,
pierces the deep fascia an average of 14 cm proximal to the medial
epicondyle

Answer 15

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

Question 16

hoe we can prevent damage to this nerve

Answer 16

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

Question 17

Adjunctive liposuction can also be
employed to facilitate atraumatic dissection and lymphatic preservation of lymphatics to decrease seroma formation

Answer 17

T

Question 18

full
motor and sensory examinations of the bilateral upper extremities,
in addition to assessment of skin quality and tone

Answer 18

T

Question 19

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

Answer 19

T

Question 20

leaving a layer of fat above the deep brachia! fascia
to preserve lymphatics and avoid significant contour irregularities

Answer 20

T

Question 21

Liposuction to the bicipital groove is avoided, WHY ?

Answer 21

to minimize contour irregularity in this region, which is known anatomically to be relatively devoid of fat

Question 22

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

Answer 22

Minibrachioplasty (Limited Medial Incision
Brachioplasty)

Question 23

the minibrachioplasty is a reasonable option to consider.
This procedure has little to no benefit for the MWL patient

Answer 23

t

Question 24

the witch of flap in minibrachioplasty which is generally
limited to 3 to 5 cm at its widest point

Answer 24

T

Question 25

The axillary elliptical incisions are made using a scalpel, and then electrocautery is used to raise the tissue in a subcutaneous plane.

Answer 25

T

Question 26

No need to undermine the medial and lateral flap for closure in minbrachioplasty

Answer 26

T The medial and lateral skin flaps may be undermined to facilitate closure, but this is typically not necessary

Question 27

Most MWL patients require extended brachioplasty

Answer 27

T

Question 28

a vertical dart (dashed lines) for dog-ear removal or to excise more redundant upper arm skin.

Answer 28

T

Question 29

An extension to the chest wall is often added and is known as an L-brachioplasty along the postrerior axillary line

Answer 29

F with the superior L-point in or near the deltopectoral groove along the anterior axillary line

Question 30

The amount of tumescent fluid should be minimized, so as to avoid large-volume swelling that may ultimately inhibit the degree of resection

Answer 30

T

Question 31

Liposuction can be don beyond the borders of the planned resection

Answer 31

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

Question 32

Reapproximation of the superficial fascia! system importantly helps maintain contour and prevents scar puckering

Answer 32

T

Question 33

Liposuction facilitates the dissection plane and leaves fat down on the deep fascia, thus helping to preserve nerves and lymphatics

Answer 33

T

Question 34

Recent studies have demonstrated intact sensory and lymphatic function following brachioplasty employing liposuction for atraumatic dissection of tissue planes

Answer 34

T This technique helps preserve the layer of fat above the deep brachia! fascia harboring the sensory nerves and lymphatics.

Question 35

Risk factors that may increase the chance of overall complications, hematoma, or infection include>>>>>

Answer 35

male gender, BMI >30, and combined procedures.

Question 36

An anterior scar placed just below the bicipital groove of the upper arm is well hidden on both anterior and posterior views

Answer 36

T

Question 37

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.

Answer 37

T

Question 38

The medial and lateral borders of the breast are defined by the sternocostal junction and the midaxillary line,

Answer 38

T

Question 39

The fourth intercostal space marks the superior boundary. The inframammary fold (IMF) delineates the inferior border of the breast

Answer 39

F The second intercostal space marks the superior boundary. The inframammary fold (IMF) delineates the inferior border of the breast

Question 40

The inframammary fold (IMF) formed by the fusion of the deep and superficial fascia with the dermis

Answer 40

T

Question 41

Layers of deep and superficial fascia support the soft tissues of the breast, as do the suspensory Cooper ligaments

Answer 41

T

Question 42

The subdermal plexus provides blood supply to the skin and nipple-areolar complex (NAC)

Answer 42

T

Question 43

Blood supply to the breast

Answer 43

branches of the internal mammary artery, the lateral thoracic artery, the thoracodorsal and thoracoacromial arteries, and multiple intercostal perforators

Question 44

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.

Answer 44

T

Question 45

Lymph node drainage of the breast

Answer 45

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

Question 46

the nipple position in MWL patients is frequently located too medial and the IMF too inferior compared with normal breast anatomy,

Answer 46

t

Question 47

Breast ptosis is nearly universal in the weight loss population.

Answer 47

T

Question 48

For the patient desiring an increase in breast size, a breast augmentation alone enough to correct the loose skin and pto· sis.

Answer 48

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.

Question 49

history of personal or family breast cancer, prior breast procedures, and up-to-date mam· mography results must be obtained somtimes

Answer 49

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

Question 50

The safest technique for breast reduction in MWL is superior-based pedicles

Answer 50

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

Question 51

Skin flaps are then raised approximately 1.5 cm in thickness in inferior base flap

Answer 51

T

Question 52

The inferior pedicle is plicated, leaving 10 cm between the base of the areola and the IMF.

Answer 52

F The inferior pedicle is plicated, leaving 5 to 5.5 cm between the base of the areola and the IMF.

Question 53

Medial, lateral, and superior sections are then tacked to the pectoralis fascia or rib periosteum

Answer 53

T

Question 54

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

Answer 54

T

Question 55

Autologous Autoaugmentation advantage ?

Answer 55

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.

Question 56

mastopexy with autologous auto augmentation using wich flap?

Answer 56

an intercostal artery perforator (ICAP) flap/spiral flap

Question 57

Doppler probe is used to confirm the perforator location posterior to the anterior axillary line

Answer 57

F anterior to the anterior axillary line

Question 58

The flaps are raised from posterior to anterior in the subfascial plane. To obtain adequate rotation of the flap for inset

Answer 58

T

Question 59

perforating vessels from the thoracodorsal system should be preserved

Answer 59

perforating vessels from the thoracodorsal system must be sacrificed.

Question 60

the mobilized ICAP flap is rotated around the inferior pedicle and secured to the chest wall medially, superiorly, and laterally

Answer 60

T

Question 61

Inadequate mobilization leads to a boxy breast with lateral fullness. Failure to preserve the intercostal arteries leads to fat necrosis

Answer 61

T

Question 62

For patients who desire more superior fullness, mastopexy with implants is recommended in one or two stages

Answer 62

T

Question 63

we can choose the size that the patients desired in this case

Answer 63

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.

Question 64

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

Answer 64

T

Question 65

The implant is placed subpectorally only?

Answer 65

F The implant is placed subpectorally in a dual plane or in a subglandular position

Question 66

In two-stage augmentation mastopexy, the mastopexy is performed first followed by the augmentation procedure 3 to 6 months later.

Answer 66

T

Question 67

In the case of two stage the implant can be out through the tradisional IMF fold?

Answer 67

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.

Question 68

axillary and back roll excision can be achieved via posterior midback/bra-line lift.

Answer 68

T

Question 69

This procedure can be performed in conjunction with breast contouring or may be added as a second stage

Answer 69

T

Question 70

There are theoretical concerns about opposing vectors if performed at the same time so how we can do both surgery together

Answer 70

however, both procedures rely primarily on lifting of the inferior tissues superiorly, so they may be performed together safely and effectively in experienced hands

Question 71

Evaluation of the degree of excess skin and adipose tissue forms the basis for operative planning

Answer 71

T

Question 72

the Pittsburgh Weight Loss Deformity Scale

Answer 72

■ 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

Question 73

the ideal placement of the final scar should be set at the level of the planned IMF. or bra strap borders

Answer 73

T

Question 74

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

Answer 74

T

Question 75

The extent of the incision

Answer 75

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

Question 76

for less severe deformity, the central skin of the back is preserved and bilateral wedge excisions are performed.

Answer 76

T

Question 77

The superior incision is made and carried down through Scarpa fascia using electrocautery

Answer 77

T

Question 78

Bra-line lift. The excess tissue ofthe back is removed at a level just below Scarpa fascia.

Answer 78

T

Question 79

The most common complication reported with this procedure is hematoma

Answer 79

F The most common complication reported with this procedure is the widening of the scar

Question 80

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

Answer 80

t

Question 81

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

Answer 81

T

Question 82

Upper body contouring can also be combined with lower body contouring procedures

Answer 82

T

Question 83

a total body lift is typically avoided secondary to excessive operative time, blood loss, and morbidity.

Answer 83

T

Question 84

a vertical dart (dashed lines) for dog-ear removal or to excise more redundant upper arm skin.

Answer 84

t

Question 85

if they desire improved arm contour. The superior incision is marked approximately one fingerbreadth above the bicipital groove

Answer 85

t

Question 86

Three-layer closure of the wound is also performed using absorbable sutures in a sequential fashion, over a drain in brachioplasty

Answer 86

T

Question 87

The breast technique employed largely depends on the current breast volume and desired breast volume

Answer 87

T

Question 88

The shaped pedicle resembles the appearance ofan implant; however, it descends more than an implant with healing, resulting in less sustained upper pole fullness.

Answer 88

T

Question 89

circumvertical or Wise-pattern mastopexy is then tailor-tacked around the implant In one-stage augmentation mastopexy,

Answer 89

T