Cosmetic Abdominoplasty/Liposuction/Abdominoplasty Flashcards
For women undergoing abdominoplasty after massive weight loss, which of the following is the best position of the navel? A) Along the line drawn between the iliac crests B) At the horizontal level of the tenth ribs C) Between the first and second tendinous inscriptions D) In the midline 10 cm above the vulvar commissure E) One-third of the distance from the xiphoid to the pubis
The correct response is Option A. As a result of the rapid increase in the number of bariatric surgical procedures performed each year, the frequency of body contouring procedures has risen concomitantly over the past decade. Among the most popular of these is abdominoplasty for resection of redundant skin on the torso. When designing the outline of skin to be resected, among the preeminent concerns is maximizing the aesthetic result of the procedure. Removal of the redundant panniculus may involve a low transverse incision only or a more extensive resection such as the fleur-de-lis or corset pattern incisions. The length of the navel stalk may limit any transposition of this structure. Accordingly, one must plan for sitting the navel in an aesthetically pleasing location to complement the finished result. The umbilicus is typically inset along a horizontal line that spans the iliac crests. This will result in the most natural appearance for most individuals. A location 10 cm above the anterior vulvar commissure would result in a placement that is unnaturally low. The other options would yield a position of the umbilicus that is too high.
A 51-year-old woman comes to the office for consultation for abdominal and lower extremity liposuction. The procedure is expected to last approximately 2.5 hours. BMI is 30 kg/m2. The patient takes an oral contraceptive. The patient reports having had a small venous thromboembolism (VTE) during lumpectomy for breast cancer that took place in her early 40s. Which of the following factors increases the risk of VTE and Caprini risk assessment score most significantly? A) Age B) History of malignancy C) History of VTE D) Length of surgery E) Use of an oral contraceptive
The correct response is Option C. In this patient, the highest Caprini risk factor is the history of a VTE, which carries a score of 3. The length of surgery is greater than 45 minutes so it would be considered major and would carry a score of 2, as would her history of malignancy. Age, obesity, and contraceptive use all carry a score of 1. This gives the patient a Caprini score of 10.
Which of the following symptoms meet the current Medicare guidelines for approval of abdominal lipectomy/panniculectomy following massive weight loss? A) Neck and back pain B) Psychological distress C) Unsatisfactory appearance D) Diastasis recti E) Recurrent intertrigo
The correct response is Option E. Medically necessary criteria for Medicare approval of abdominal lipectomy/panniculectomy include: Inability to walk normally Chronic pain and ulceration created by the abdominal skin fold When the panniculus hangs below the level of the pubis Intertrigo of the pannus that is persistent or recurrent over a 3-month period while receiving appropriate medical therapy Stable weight for at least 6 months and 18 months after gastric bypass surgery According to Medicare guidelines, the other four options listed are not considered reasons that make this procedure medically necessary: Treatment of neck and back pain Repairing abdominal wall laxity or diastasis recti Improving appearance Treating psychological symptomatology
A 48-year-old woman undergoes liposuction of the abdomen, flanks, and thighs. Liposuction is performed using 4 L of infiltration fluid. Each liter is mixed with 50 mL of 2% plain lidocaine and 1 mL of 1:1000 epinephrine. At which of the following times after infiltration are concentrations of lidocaine in the blood expected to be the highest in this patient? A) Immediately after injection B) 1 hour after surgery C) 2 to 4 hours after surgery D) 8 to 18 hours after surgery E) 24 to 48 hours after surgery
The correct response is Option D. The safe dosage of lidocaine in liposuction is 35 to 55 mg/kg. Peak lidocaine levels are reported to be 8 to 18 hours after infiltration. Oftentimes, patients are discharged to home when peak levels occur. Surgeons should keep this in mind when calculating lidocaine dosage.
A 35-year-old woman comes to the office for consultation regarding a tummy tuck. She wants the scar as low as possible, but she does not want a lower vertical midline scar. Physical examination shows mild upper and lower abdominal skin excess and rectus abdominis diastasis. BMI is 27 kg/m2. Abdominoplasty and repair of diastasis are planned. Intraoperatively, there is marked tension on the lower central abdominal flap closure. Which of the following is the most appropriate maneuver to decrease the tension on the repair? A) Creation of a 3-cm transverse umbilical opening B) Liposuction of the upper abdomen C) Relaxing incision of the external oblique fascia D) Scoring of Scarpa fascia to the dermis E) Use of progressive tension sutures
The correct response is Option E. Progressive tension sutures are placed from Scarpa’s fascia to the abdominal wall fascia. This helps close the dead space, minimize flap movement, and minimize seroma rate. When placing these sutures with progressive tension, final tension on the abdominal suture line can be lessened. In so doing, healing complications can be reduced. The more common method for reducing tension on flap closure is to close the native umbilical skin opening in a vertical direction. This technique leaves a vertical incision in the midline of the abdominal flap. The need for revision of this scar is not infrequent. Further, most patients want to avoid this scar. Creating a 3-cm transverse incision for the umbilicus would decrease the tension on the flap; however, the appearance of the umbilicus would be aesthetically unacceptable. Relaxing incision of the external oblique fascia is used for closure of ventral herniorrhaphy and would not lessen skin flap tension. Scoring Scarpa’s fascia to the dermis would injure the subdermal vascular plexus, on which the vascularity of the abdominal flap depends. Upper abdominal liposuction can be performed at the same time as abdominoplasty, provided care is taken to maximize preservation of the lateral rectus perforators. It would not be a solution to minimize skin tension.
Compared with liposuction, which of the following is the greatest advantage of cryolipolysis? A) No procedural discomfort B) No risk of bruising C) No risk of posttreatment swelling D) No surgical intervention E) Shorter duration of treatment time
The correct response is Option D. Nonsurgical fat freezing treatment (CoolSculpting) is a method of noninvasive fat reduction that occurs via the use of cryolipolysis. It is a noninvasive technique that takes place in an office setting and does not involve the use of surgery. Following CoolSculpting treatment, patients have some aspect of bruising and swelling, which can last for up to several weeks. Results of CoolSculpting treatments typically take 3 to 4 months to develop. Results are additive, however, with multiple treatments. CoolSculpting involves the utilization of different applicators that have been developed to treat various parts of the body effectively. Each actual treatment is for 1 hour; however, most areas of the body may require multiple treatments to be effectively managed. Treatment times for an abdomen can range from 2 to 6 hours alone, whereas outer thighs are treated for at least 2 hours per side and inner thighs at least 1 hour per side. Although not all of these treatments need to be performed in one sitting, the total time for CoolSculpting treatments for most areas of the body are much longer than it would take to surgically perform liposuction. In general, however, CoolSculpting is a less expensive treatment option compared with liposuction as there is no fee necessary for anesthesia or operating-room costs.
During routine brachioplasty, which of the following nerves is/are most likely at risk during typical dissection? A) Lateral antebrachial cutaneous nerve B) Medial antebrachial cutaneous nerve C) Sensory branches of the axillary nerve D) Sensory branches of the radial nerve
The correct response is Option B. The medial antebrachial nerve is most at risk for injury during routine brachioplasty surgery secondary to its superficial location within the subcutaneous tissue within the area of typical skin and soft-tissue excision. This nerve arises from the medial cord of the brachial plexus 78% of the time and from the lower trunk in 22%. After emerging from the axilla, the medial antebrachial cutaneous nerve travels medial to the brachial artery and lies adjacent to the basilic vein at the distal upper arm. In the distal or mid brachium, this nerve pierces the deep fascia to become very superficial running above the deep fascia at an average of 14 cm proximal to the medial epicondyle. Despite some minor anatomical variability, this nerve has been found to be consistently present in the deep plane of dissection for the standard brachioplasty technique.
A 34-year-old woman is evaluated for body contouring after Roux-en-y gastric bypass surgery 6 months ago. There is no evidence of malabsorption. BMI is 36.3 kg/m2. She had a 75-lb (34-kg) weight loss and is actively losing weight. The patient reports low back pain. Which of the following is the most appropriate next step in management? A) Liposuction B) Panniculectomy C) Revision of the gastric bypass surgery D) Upper GI series E) Observation
The correct response is Option E. After bariatric surgery, patients can continue to lose weight as a result of the surgical procedure for approximately 2 years. Thus, most recommendations call for waiting until patients are 12 to 18 months out from their bariatric surgery and at a stable weight for 3 to 6 months. Ideally, patients should be within 10 to 15% of their goal weight. In this case, the patient is still within the time frame of active weight loss, and notes that she is actively losing weight. Thus, the appropriate answer is to wait until weight loss has stabilized. Because this patient is actively losing weight and there are no clinical findings of any issues such as malabsorption, there is no indication currently to evaluate her with an upper GI series or revise her bypass. In addition, as noted above, the risks for surgery are increased at this patient’s BMI. Thus, elective liposuction or panniculectomy is not appropriate at this time. Furthermore, because the patient is actively losing weight, the risk for revision surgery to address additional skin laxity that may develop with further weight loss makes undertaking these procedures not appropriate at this point in time.
Compared with standard suction-assisted lipectomy, laser-assisted liposuction has been shown to decrease which of the following? A) Contour irregularities B) Ecchymosis C) Postoperative pain D) Skin necrosis E) Swelling
The correct response is Option C. A prospective, randomized, double-blind study involving human subjects compared the effects of laser-assisted lipoplasty with suction-assisted lipoplasty. No significant difference was noted between the two groups with respect to cosmetic outcome, ecchymosis, edema, skin retraction, or surgical time. The only measured potential benefit of the laser-assisted technique was an overall decrease in postoperative pain.
A 35-year-old woman comes to the office for lipodystrophy of the upper arms. Physical examination shows negligible skin laxity; pinch test shows a thickness of 3 cm of the entire upper arm and the chest wall. Which of the following is the most appropriate surgical intervention? A) Extended brachioplasty B) Limited medial brachioplasty C) Mini brachioplasty D) Suction-assisted lipectomy E) Traditional brachioplasty
The correct response is Option D. Skin laxity is the single greatest determinant of whether liposuction is an appropriate modality in an algorithmic approach to upper arm lipodystrophy. The determination of excessive fat can be made by the pinch test, and patients with greater than 1.5 cm of fat on a pinch test may be candidates. The classification of lipodystrophy, described by Rohrich et al., includes skin excess, fat excess, and the location of skin excess. Where there is skin excess, the skin must be excised for a favorable result. Liposuction alone can exacerbate the appearance and presence of excess skin. Similarly, skin laxity is a predictor of liposuction success. With marked laxity, the skin is unlikely to have enough elastic properties to retract. Although there are some papers that show increased retraction of skin with laser liposuction, this has not been shown to be a consistent result in large-scale studies.
A 37-year-old woman reports nontender swelling of the lumbar area after undergoing lower body lift following massive weight loss. Examination shows tense swelling and a positive fluid wave test. Percutaneous needle aspiration is performed on a weekly basis, and fluid is still present after three aspirations of 150 mL each of a clear, yellowish serum. Which of the following is the most appropriate next step in management? A) Compression B) Operative incision and drainage C) Placement of a closed suction drain tube D) Use of an ipsilateral gluteus maximus muscle advancement flap
The correct response is Option C. Among the most common complications following body contouring for post-massive weight loss-induced skin laxity is seroma, occurring in up to 35 to 50% of patients. To minimize the risk for seroma, preoperative nutritional repletion, especially for protein, and intraoperative use of closed suction drains, aggressive minimization of dead space, limited degree of skin flap undermining, and use of well-fitted elastic compression garments are among the techniques that are commonly recommended. None of these, even in combination, can completely guarantee the elimination of this complication. After several ineffective aspirations, compression garments alone are not likely to eliminate a seroma for this patient. The most appropriate next management measure for this patient’s seroma is ultrasound-directed percutaneous closed suction drain placement. Operative incision and drainage is not indicated unless the closed drain fails, following failed sclerosant therapy, or if the seroma is shown to be infected. A muscle flap is not indicated in this setting.
A 35-year-old woman with a history of hypertension is evaluated for body contouring. Physical examination shows generalized abdominal adiposity and moderate infraumbilical pannus. The patient undergoes abdominoplasty and large-volume liposuction after induction of epidural anesthesia. A super-wet technique is used and a total volume of 5500 mL is removed. Which of the following factors poses the greatest risk of death for this patient? A) Abdominoplasty B) Epidural anesthesia C) Hypertension D) Liposuction volume E) Super-wet technique
The correct response is Option A. The cumulative effect of multiple procedures performed during a single operation increases the potential that complications may develop. Large-volume liposuction, combined with other procedures such as abdominoplasty, can cause serious complications. Death associated with isolated lipoplasty is rare (0.0021%, or one per 47,415), but mortality increases significantly when lipoplasty is combined with other procedures. When combined with non-abdominoplasty procedures, lipoplasty mortality increases to one per 7314; when combined with abdominoplasty, with or without other procedures, the lipoplasty mortality increases to one per 3281. The presumed benefits of combined procedures must thus be weighed against potential untoward events. Studies indicate that epidural anesthesia combined with the infusion of anesthetic infiltrate provides patients with a consistent intraoperative comfort level. Data from the few anesthesia studies that have specifically assessed patients undergoing liposuction confirm the safety of general anesthesia, epidural anesthesia, spinal anesthesia, moderate sedation, and local anesthesia for this procedure. It should be noted, however, that epidural anesthesia and spinal anesthesia can cause vasodilation and hypotension, thereby necessitating the administration of excess fluid and increasing the risk of fluid overload. Based on the patient’s history, physical examination, review of systems, laboratory testing, and/or a medical specialist’s evaluation, the physician should select the patient’s American Society of Anesthesiologists (ASA) physical classification rating: Type 1: A normal healthy patient; Type 2: A patient with mild systemic disease; Type 3: A patient with severe systemic disease; Type 4: A patient with severe systemic disease that is a constant threat to life. ASA Type 1 and Type 2 patients are candidates for ambulatory and office-based surgery. The patient described is a Type 2 patient, a classification rating that represents patients who have any of the following conditions that are under control without systemic compromise: diabetes mellitus, hypertension, asthma, gastroesophageal reflux disease, peptic ulcer disease, hematologic disorders, arthritis, and neuropathy. Large-volume liposuction is defined as the removal of 5000 mL or greater of total aspirate during a single procedure. A review of the scientific literature shows that there are no scientific data available to support a specific volume maximum at which point liposuction is no longer safe. The super-wet technique, introduced in the mid-1980s, uses larger volumes of subcutaneous infiltrate, whereby 1 to 2 mL of solution is infused for each 1 mL of fat to be removed. The infiltrate solution consists of saline or Ringer’s lactate with epinephrine and, in some cases, lidocaine. Using this method, blood loss generally decreases to less than 1 to 2% of the aspirate volume.
An otherwise healthy 41-year-old woman who underwent Roux-en-Y gastric bypass surgery 24 months ago, followed by a 120-lb (54-kg) weight loss that she maintained for 6 months, undergoes plastic surgery evaluation for a panniculectomy. Medical history includes hypothyroidism that is controlled with levothyroxine. Preoperative cardiovascular examination shows no abnormalities, and results of a pregnancy test on the day of surgery are negative. She undergoes panniculectomy and thigh lift, and on extubation, the patient is lethargic and confused. ECG shows sinus tachycardia, and she remains somnolent and confused. Analysis of thyroid-stimulating hormone and cardiac enzymes, chest x-ray study, and ventilation-perfusion scan show no abnormalities. Which of the following is the most likely diagnosis? A) Acute thyroiditis B) Diabetic ketosis C) Pulmonary embolism D) Undiagnosed pregnancy E) Vitamin B1 (thiamine) deficiency
The correct response is Option E. Thiamine deficiency is most often identified shortly after bariatric surgery but can be diagnosed later. Some patients can develop Wernicke-Korsakoff encephalopathy (WKE). Body stores of thiamine can last from 3 to 6 weeks, and thiamine deficiency is more associated with decreased dietary intake. Although clinical manifestations are very uncommon, and WKE is considered a rare complication, approximately 11% of patients who have undergone Roux-en-Y gastric bypass surgery and take vitamin supplementation show evidence of thiamine deficiency 2 years postoperatively. The hallmark of thiamine deficiency is neurologic symptoms, but in contrast to WKE, patients rarely exhibit confusion, ataxia, and oculomotor abnormalities. If thiamine deficiency is not recognized and treated, it can have devastating results, including irreversible brain damage and death. Full nutritional workup of patients is critical. Confusion is a symptom of diabetic ketosis, but diabetic ketosis is notable for signs of dehydration and excessive thirst or urination, and is associated with Kussmaul respirations. Acute thyroiditis has symptoms of pain and swelling of the anterior neck. Pulmonary embolism can have symptoms of respiratory distress and right-sided heart strain. Early pregnancy often results in nausea, but not lethargy and confusion.
A 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.
A 32-year-old woman is evaluated for lipodystrophy of the central abdomen with skin laxity. She desires volume reduction as well as improvement of the skin laxity. The patient is scheduled for superficial liposuction of the abdomen. Which of the following postoperative complications is most likely in this patient? A) Contour irregularities B) Hyperpigmentation C) Infection D) Seroma E) Skin necrosis
The correct response is Option A. The subcutaneous fat of the abdomen is anatomically arranged in two layers: superficial and deep. The superficial adipose layer is located 1 to 2 mm below the dermis and is dense and compact with numerous septations. The deep adipose layer is loose and areolar with few septa. Conventional or traditional liposuction is performed within the deep adipose layer with larger cannulas. Superficial liposuction or subdermal liposuction involves the removal of fat from the superficial compartment found 1 to 2 mm below the dermis, disrupting the extensive septations. Most complications following liposuction are minor and resolve without further surgical intervention. However, the most common complications following superficial liposuction are contour irregularities. Less common complications associated with superficial liposuction include seroma, hyperpigmentation, infection, hypertrophic scar, chronic induration, skin necrosis, and infection.
A 40-year-old woman, gravida 2, para 2, with abdominal laxity and rectus diastasis is scheduled to undergo abdominoplasty with rectus plication. Which of the following intraoperative nerve blocks is likely to provide postoperative analgesia to the greatest area of lower abdominal skin for this patient? A) Direct midline injection of plication area B) Iliohypogastric nerve block C) Ilioinguinal nerve block D) Subcostal nerve block E) Transversus abdominis plane block
The correct response is Option E. Innervation of the anterolateral abdominal wall arises from the anterior rami of spinal nerves T7 to L1. These branches include the intercostal nerves (T7-T11), the subcostal nerve (T12), and the iliohypogastric and ilioinguinal nerves (L1). Because these nerves travel in the plane between the transversus abdominis and internal oblique muscles, they can be conveniently blocked in this area with a single transversus abdominis plane (TAP) block on each side. Although the other nerve block techniques are frequently used in combination, each covers a smaller territory or single dermatome. The TAP block may be performed via several different approaches. Most experts agree that there is a reliable block of the T10 to L1 dermatomes when the lateral approach from the triangle of Petit is used. The subcostal approach of the TAP block can give a more cephalad block. The combination of bilateral TAP blocks and rectus sheath injections has been found to decrease the need for postoperative narcotic use after abdominoplasty. It has also been useful for patients receiving transverse rectus abdominis musculocutaneous (TRAM) and deep inferior epigastric artery perforator (DIEP) flaps. The TAP block was also found to be superior to conventional ilioinguinal and iliohypogastric nerve blocks in a comparison study of open inguinal hernia repairs.
Which of the following is the most common reason for reoperation after brachioplasty in patients who have undergone significant weight loss? A) Hematoma B) Hypertrophic scar C) Infection D) Seroma E) Wound dehiscence
The correct response is Option B. In general, patients are satisfied with the results of brachioplasty. Complications are not uncommon and some studies report complication rates as high as 50%. Most of these complications are minor in nature. Wound dehiscence is managed with dressing changes. Hematoma and seromas are typically managed with observation or aspiration. In the case of infections, the majority are managed with oral antibiotics. The most common reason for additional surgery after brachioplasty is to revise the scar. Many patients will have an unfavorable scar that either hypertrophies or widens. This can be addressed by a scar revision, laser treatment, or triamcinolone acetonide (Kenalog) injection.
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 35-year-old woman undergoes abdominoplasty and inner thigh liposuction. After the procedure, burning pain radiating down the right anterior thigh is noted. Pain increases when the patient stands and walks. Injury to which of the following nerves is most likely in this patient? 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 that increase with standing, walking, or hip extension. 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 ilioinguinal nerve arises from the fusion of T12 and L1 nerve roots and pierces the transversus abdominis and internal oblique muscles. The nerve then supplies sensory branches to supply the pubic symphysis, the superior and medial aspect of the femoral triangle, and either the root of the penis and anterior scrotum in the male or the mons pubis and labia majora in the female. 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. The iliohypogastric nerve arises primarily from L1. The distribution of the cutaneous sensation of the iliohypogastric nerve most commonly is 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. Saphenous nerve symptoms of entrapment may include a deep aching sensation in the thigh, knee pain, and paresthesia in the cutaneous distribution of the nerve in the leg and foot.
A 39-year-old woman is referred for abdominoplasty. She has a history of severe uterine fibroids, and her gynecologist is planning a total abdominal hysterectomy (TAH). The patient would like to have the abdominoplasty and the TAH performed at the same time. Which of the following is the most appropriate response to this patient’s inquiry? A) Combining the surgeries can be done safely via any approach for TAH B) The gynecologist may perform TAH, but the abdominoplasty flap must be raised first C) The patient’s risk of a thromboembolic event is decreased by having one large surgery D) TAH cannot be combined with abdominoplasty
The correct response is Option A. Performing abdominoplasty in combination with other procedures has become a much more common request from patients. Advantages to this approach would include one recovery period versus multiple (which would minimize time away from work and or family, financial advantage to the patient, and a reduced need for multiple hospitalizations and exposure to anesthesia). Several studies have proven the safety of performing abdominoplasty combined with intra-abdominal procedures such as total abdominal hysterectomy (TAH). While the safety profile of combining these surgeries has been well proven, the risk of thromboembolic events is increased due to the extended time of surgery, so that aggressive deep venous thrombus prophylaxis must be administered perioperatively such as set forth by the Plastic Surgery Task Force on Deep Venous Thrombosis Prophylaxis. A TAH may be done via open or laparoscopic approach, depending on the gynecologist’s preference or patient’s chosen method. In addition, as robotically assisted gynecologic procedures have gained widespread acceptance, this approach for a TAH may also be combined with abdominoplasty surgery. Typically, if a laparoscopic or robotic method were chosen, the gynecologist would start the procedure; this way the port scars may be planned such that they can be excised within the abdominoplasty flap to be removed. Although the abdominoplasty flap may be raised off of the fascia before port placement, this usually causes the ports to be more unstable without the added support of the skin and soft tissues to properly hold them in place.
A 37-year-old man is scheduled to undergo bilateral brachioplasty to correct redundant arm skin due to massive weight loss following gastric bypass surgery. Which of the following methods is most appropriate to minimize sensory cutaneous nerve injury during this procedure? A) Design the longitudinal incision anterior to the bicipital groove B) Divide the intermuscular septum while resecting skin and fat C) Elevate and transpose the basilic vein before closure of the brachioplasty defect D) Leave at least 1 cm of fat over the brachial fascia in the proximal arm E) Maintain a sharp dissection plane deep to the brachial fascia
The correct response is Option D. Among the complications that have been reported following brachioplasty are injuries to the sensory nerves that traverse the medial arm. The most likely nerve to be injured is the medial antebrachial cutaneous nerve. It perforates the antebrachial fascia at a fairly constant distance of 14 cm proximal to the medial epicondyle, putting it at a greater risk of injury than either the ulnar or median nerves, both of which lie deep to the brachial fascia. It has a variable relationship with the basilic vein, but this structure is never transposed during brachioplasty. There is a greater danger to nerve injury when the dissection is conducted deeper than the Scarpa’s fascia, therefore dissection deep to the brachial fascia or harvest of the intermuscular septum is contraindicated. A layer of subcutaneous fat at least 1 cm thick should be left over the deep fascia to minimize injury to the sensory nerves in the arm. Placing the longitudinal incision slightly posterior to the bicipital groove decreases chances for injury to the nerve as well.
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 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 53-year-old woman comes to the office for evaluation of abdominal skin redundancy. Physical examination shows muscle laxity and lipodystrophy of the central abdomen and flank regions. Abdominoplasty and liposuction of the flank and anterior abdominal skin are planned. After this combined procedure, the patient is at greatest risk for skin necrosis of which of the following abdominal zones?
A) I
B) II
C) III
D) IV
The correct response is Option A.
Abdominoplasty in combination with liposuction has been associated with a higher risk of complications. Combining both procedures has been reported to increase the risk of delayed healing, thrombotic emboli, fat emboli, skin necrosis, and fat necrosis. Increased complication rates are reported in patients with risk factors such as obesity, smoking, and diabetes mellitus. Direct undermining of the abdominal skin combined with liposuction can lead to vascular compromise of the overlying skin. The blood supply to the abdominal wall is divided into three zones: zone I, mid abdomen supplied by the deep inferior epigastric artery; zone II, lower abdomen supplied by the external iliac artery; and zone III, lateral abdomen and flanks supplied by the intercostal, subcostal, and lumbar arteries. Zone IV has not been described. Following abdominoplasty, elevation of the abdominal flap disrupts the blood supply from zones I and II, leaving the flap to be perfused by blood vessels from zone III. Liposuction with abdominoplasty of the central abdomen, zone I, is associated with the highest rate of skin necrosis. “Safe zones” include the flanks and upper lateral abdomen.
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 60-year-old woman comes to the emergency department because of shortness of breath and right-sided chest pain 2 days after she underwent an uncomplicated abdominoplasty. Heart rate is 100 bpm, respiratory rate is 20/min, blood pressure is 110/60 mmHg, and oxygen saturation is 92% on room air. Chest x-ray study shows no abnormalities. Serum creatinine concentration is 2.5 mg/dL. Which of the following is the most appropriate first step in management?
A) CT angiography
B) Emergency cardiac catheterization
C) Enoxaparin therapy
D) Lower extremity venous Doppler
Ventilation/perfusion scanning
The correct response is Option E.
The most appropriate first step in management is to obtain a ventilation/perfusion scan. The patient described presents with the clinical picture of a pulmonary embolus (PE). Normal chest X-ray study rules out an obvious pulmonary process like pneumonia, atelectasis, or pneumothorax. The right-sided strain pattern on electrocardiography points to a PE as well. Vitals are abnormal, but she is hemodynamically stable. CT angiography (CTA) would have been the investigation of choice; however, serum creatinine is abnormally high, which precludes giving her the high doses of contrast dye a CTA would require. Empirically starting her on anticoagulation is another management option, though one has to weigh the risk-benefit of full-anticoagulation therapy so soon after major surgery. However, subcutaneous enoxaparin therapy in a patient with renal insufficiency is not ideal. Instead, systemic heparin therapy would be the agent of choice because it is not dependent on renal excretion, has a much shorter half-life, and its therapy can easily be measured with activated partial thromboplastin time levels. Therefore, it can be titrated more reliably, and its anticoagulation effects can be shut off quickly if the need arises.
A venous Doppler examination of the lower extremities will probably need to be done, but it is not the first step in management. Additionally, it does not diagnose a PE. An emergent cardiac catheterization is not indicated because this is not an acute myocardial ischemic event.
A ventilation/perfusion scan is performed in situations where an angiogram (conventional or CTA) is not indicated or available. It is especially useful in patients with renal insufficiency because the perfusion portion does not utilize contrast that could negatively affect the kidneys, but rather uses a radioactive tracer. The ventilation/perfusion scan helps stratify the probability of a patient having a PE, and thus helps the clinician to choose the appropriate way to potentially treat the patient.
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.
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.
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 32-year-old woman, gravida 3, para 3, comes to the office for consultation regarding a slimmer abdominal contour. She says the most weight she lost after pregnancy was 30 lb (13.6 kg). Current BMI is 23 kg/m2. Examination shows mild diastasis recti and vertical skin redundancy above and below the umbilicus. No hernias or scars are noted. Which of the following is the most appropriate treatment?
A) Suction-assisted lipectomy
B) Repair of the diastasis with prosthetic mesh and cryolipolysis
C) Miniabdominoplasty and suction-assisted lipectomy of the epigastrium
D) Abdominoplasty with rectus plication
E) Fleur-de-Lis abdominoplasty
The correct response is Option D.
In addition to a thorough medical history, careful analysis of the patient’s goals and evaluation of the anatomy is the basis for correctly selecting the optimum choice for aesthetic restoration of the abdomen after child bearing. This patient’s skin redundancy above and below the navel requires that panniculectomy incorporate downward tension for the portions superior to and inferior to the umbilicus. Miniabdominoplasty fails to include supraumbilical skin tensioning. Liposuction alone may actually worsen the degree of skin laxity by deflating fat compartments or disrupting musculocutaneous suspensory fasciae. It is unlikely that prosthetic material will be necessary to repair a diastasis when plication (folding adjacent fascial halves with sutures) suffices unless a concurrent hernia of significant proportions exists. Traditional abdominoplasty incorporates mobilization of the abdominal panniculus, addresses laxity above and below the navel, and may incorporate more recent techniques such as progressive tension sutures to ensure an optimum aesthetic result while minimizing the need for revision. Fleur-de-Lis abdominoplasty involves a vertical incision and is not indicated. Cryolipolysis is not effective in this level of skin laxity.
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?
The correct response is Option D.
Traditional brachioplasty comprises a T-shaped scar along the length of the arm and the axilla. This patient has excess skin on her arm, which dictates the necessity for an excisional procedure. Further liposuction of any modality will exaggerate her presentation further, including Vaser liposuction, a form of ultrasound-assisted liposuction, and laser-assisted liposuction, both of which are reported to tighten skin through heating its undersurface. There is no evidence to support Thermage as an effective treatment for lax skin. Lipobrachioplasty is a technique which safely combines liposuction with excisional surgery, performing liposuction on the proposed area to be excised. In a thinned arm, potential risks of neuropathy and seroma that accompany liposuction are unnecessary in a patient with lax skin that requires excision to improve contour. Limited incision brachioplasty with excision limited to an ellipse in the axilla, with or without liposuction, provides very limited results with regard to improving overall arm contour, particularly with moderate-to-severe skin redundancy.
A 21-year-old female cheerleader is scheduled to undergo suction-assisted lipectomy for contouring of the outer thigh. She is physically fit and has lost 10 lb (4.5 kg) over the past 6 months. Current weight is 145 lb (65.8 kg). Preoperative examination showed adiposity along the outer thigh area. To decrease the risk of postoperative deformities in this patient, particular attention should be paid to which of the following zones of adherence?
A) Gluteal crease
B) Iliotibial tract
C) Lateral gluteal depression
D) Mid medial thigh
E) Posterior thigh
The correct response is Option C.
The key element to avoid postoperative deformities in liposuction is avoiding the zones of adherence. These are zones where the superficial fascial system sends elements through the deep compartment attaching to the investing fascia of the underlying musculature. These zones of adherence accentuate localized fat deposits between them. The lateral gluteal depression is just superior to the outer lateral thigh and attention to that zone is important when performing liposuction along the outer thigh area. The other zones are not related to the outer thigh, except the inferolateral iliotibial tract, which is distal to the area of concern.
A 30-year-old woman is brought to the emergency department 1 day after undergoing outpatient liposuction because of difficulty breathing and confusion. A tumescent technique with lidocaine was used during the procedure, in which 4000 mL of tumescent fluid was infiltrated and 4000 mL of lipoaspirate was removed. Physical examination shows respiratory distress and petechial rash. Which of the following is the most likely cause of this patient’s condition?
A) Drug allergy
B) Fat embolism
C) Lidocaine toxicity
D) Pulmonary edema
E) Pulmonary embolism
The correct response is Option B.
A known risk of liposuction is fat embolism syndrome (FES), and clinical examination remains the gold standard for diagnosis. The three classic symptoms of FES are respiratory distress, decreased cerebral function, and petechial rash. This generally occurs within 48 hours postoperatively. With manual disruption of both fatty tissue and blood vessels that occurs with liposuction, microparticulate fat showers the lung, brain, kidney, and skin with emboli, leading to mechanical obstruction and/or a biochemical inflammatory reaction. Overall mortality from FES after liposuction is approximately 10 to 15%.
Lidocaine at high concentrations can cause serious central nervous system disturbances, including anxiety, agitation, psychosis, seizures and/or coma, and cardiovascular toxicity, including arrhythmias and hypotension. Symptoms of toxicity include light-headedness, euphoria, digital paresthesia, restlessness, and drowsiness. Symptoms of objective toxicity include nausea, vomiting, tremors, blurred vision, tinnitus, confusion, excitement, psychosis, and muscular fasciculations. Seizures and cardiorespiratory depression occur typically when blood levels reach 8 to 12 mcg/mL. Above this level, subjects may become comatose, with respiratory arrest and cardiac asystole. A rash is not associated with lidocaine toxicity. The safe dose of lidocaine has been established as 35 mg/kg during liposuction, and some authors suggest using 55 mg/kg may be safe.
Anaphylaxis from a drug allergy also does not cause a rash but can cause respiratory distress from laryngeal edema.
Pulmonary edema is characterized by respiratory distress that does not respond to oxygen therapy. This can occur because of fluid overload or from physiologic issues related to extubation.
Pulmonary embolism must be considered with respiratory distress but is not associated with rash and can occur at any time postoperatively.
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 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 46-year-old woman scheduled to undergo abdominoplasty and lipoplasty is concerned about postoperative discomfort. A regional block during the procedure is planned for pain management to minimize the need for narcotics. The anesthetic for the regional block should be injected to which of the following tissue planes?
A) Between the external oblique and the internal oblique
B) Between the internal oblique and the transverse abdominis
C) Between the skin and the external oblique
D) Between the transverse abdominis and the transverse fascia
E) Between the transverse fascia and the peritoneum
The correct response is Option B.
The thoracolumbar nerves that innervate the anterior abdominal wall travel as multiple mixed segmental nerves that branch and communicate widely in the transverse abdominis plane (TAP), located between the internal oblique and transverse abdominis muscles.
The TAP regional block provides abdominal wall analgesia by affecting the sensorial afferent nerves of T6 to L1 found in this plane. Local anesthetic injected into the TAP has been shown to decrease the amount of postoperative narcotic requirements in abdominal wall surgery.
An otherwise healthy 38-year-old woman with a BMI of 34 kg/m2 is scheduled to undergo suction lipectomy of the abdomen, hips, and thighs using a tumescent technique and a 5000-mL lipoaspirate. The infiltrate contains lidocaine and epinephrine. Which of the following adjustments to the planned procedure is most appropriate to decrease the risk of intraoperative complications?
A) Decreased rate of infusion of the wetting solution
B) Infiltration of all areas simultaneously
C) Removal of the epinephrine from the wetting solution
D) Substitution of bupivacaine for lidocaine
E) Use of a superwet technique instead of tumescent
The correct response is Option E.
In the tumescent technique of infiltration of wetting solution, the tissues are infiltrated with roughly a 3:1 ratio of wetting solution to lipoaspirate. This is generally done to effect, with the tissues becoming firmer once engorged with fluid. In large-volume liposuction (greater than 4 L), it is especially important to understand the possible side effects of the constituent parts of the wetting solution, including the volume of administration, the local anesthetic, and the epinephrine.
In terms of lidocaine toxicity, there are various factors to take into consideration, including the level and rate of drug absorption, drug interactions, fluid management, prothrombogenic factors, and volume of the wetting solution and aspirate. According to the ASPS Safety Committee Advisory on Liposuction, two options are available to decrease the risk of lidocaine toxicity in large-volume liposuction cases: 1) decrease the concentration of lidocaine in the wetting solution; and 2) use smaller volumes of infiltrate by applying the superwet technique (1:1 ratio of infiltrate: lipoaspirate) rather than the tumescent technique. Furthermore, one can omit the lidocaine altogether from the infiltration solution. The pressure and rate of infusion of the wetting solution do not affect the rate of lidocaine absorption. Infiltration of all areas simultaneously will be counterproductive. The use of epinephrine in wetting solutions is critical because it causes vasoconstriction, which results in both improved hemostasis as well as delayed absorption of the anesthetic agent, which prolongs its effect, decreases the amount of anesthetic needed, and reduces the risk of lidocaine toxicity. Therefore, its removal from the wetting solution is not indicated. However, in large-volume liposuction cases, staged infiltration of multiple anatomical sites may provide a wider safety margin.
The use of bupivacaine and prilocaine in wetting solutions has not been clinically studied or assessed. Bupivacaine should be used with caution if added to infiltrate solutions because of its slow elimination and reversal and its potential for severe side effects involving the cardiovascular, neurologic, and hematologic systems.
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 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.
A 46-year-old woman comes to the office for consultation regarding abdominal contouring surgery 18 months after gastric bypass surgery. She has lost 125 lb (57 kg). Physical examination shows excess abdominal, flank, and back skin. Which of the following nutritional parameters is most likely abnormal in this patient at this time?
A)Albumin
B)Calcium
C)Folate
D)Iron
E)Vitamin B12 (cobalamin)
The correct response is Option D.
Following gastric bypass, many patients have poor nutrition that may adversely affect post-bariatric surgical outcomes. Advanced age, changes in body mass index, and presence of dumping syndrome may contribute to the patient’s overall nutritional status. Preoperative assessment is important in identifying patients with inadequate nutrition. Evaluation should include protein-calorie intake, serum protein measures, vitamin and mineral status, coagulation, liver function, and electrolytes.
Iron deficiency is the most common abnormality found in post-gastric bypass patients. Despite iron supplementation, 50% of patients show evidence of low ferritin concentrations. Vitamin B12 (cobalamin) deficiency is often detected. Deficiencies in calcium and folate are less common.
Protein deficiency identified by hypoalbuminemia has been reported to be as high as 14% in patients following gastric bypass surgery.
A 35-year-old woman comes to the office 2 weeks after undergoing abdominoplasty. She says she has felt bloated for the past week, and that she expects her menstrual period in 2 days. Physical examination shows ballottable swelling of the infraumbilical region. Which of the following is the most appropriate next step in management?
A) Application of a compression garment
B) Diagnostic ultrasonography
C) Doxycycline sclerosis
D) Needle aspiration
E) Oral administration of a diuretic agent
The correct response is Option D.
Seroma formation is the most frequent complication of abdominoplasty procedures. The occurrence rate quoted in the literature varies from 0.3 to 90%. The most common figure is 7 to 35%. The diagnosis of seroma can usually be made on physical examination. Ballottable swelling or fluid wave is both visible and palpable and represents the sine qua non of seroma.
In this patient, a needle aspiration should be performed. It is not unusual for seroma to recur, and additional aspirations may be required on a weekly basis. The average seroma takes two to three aspirations to eradicate. If seroma is ignored, it can lead to a permanent condition that requires operative excision. Risk factors for increased seroma formation include BMI greater than or equal to 30, concomitant liposuction, large skin resections, and shear forces. Most plastic surgeons put their patients in compression garments postoperatively; however, studies have shown that garments do not prevent seromas.
Diagnostic ultrasound is an unnecessary test when the patient has a ballottable mass. Doxycycline sclerosis is indicated when aspiration is unsuccessful or if the suction drains cannot be removed because of persistent high-volume output.
Oral diuretics will not cure seroma.
A 40-year-old woman comes to the office because she is dissatisfied with the “deflated” appearance of her buttocks (shown) after undergoing gastric bypass surgery, followed by a 100-lb (45-kg) weight loss. Physical examination shows skin laxity and deflation of the buttocks. In addition to performing a lower body lift, which of the following is the most appropriate management of the buttock deformity?
A) Application of external radiofrequency (Thermage)
B) Augmentation with gluteal artery perforator flap coverage
C) Fat grafting
D) Implantation of prostheses
E) Suction lipectomy
The correct response is Option B.
Gluteal changes related to loss of volume, ptosis, and skin laxity following massive weight loss require aggressive surgical techniques to improve contour and augmentation.
External radiofrequency (Thermage) does not address deflation and has shown conservative results with regard to skin tightening. It does not offer the degree of tightening that would adequately treat the massive weight-loss patient. The gluteal region in patients who have sustained massive weight loss following gastric bypass surgery is characterized by excessive skin and exaggerated fat loss. Lower body lift procedures remove excess skin and lift sagging buttock tissue, but they do not address deflation and may result in further gluteal flattening. Autologous gluteal augmentation flaps, such as those vascularized by the superior and inferior gluteal artery perforator arteries, can be transferred reliably during lower body lifts to add volume and projection to the buttocks.
Fat grafting is the most prevalent form of gluteal augmentation with the greatest safety profile, currently surpassing gluteal prostheses. The greatest challenge in using autologous fat in a patient who has sustained massive weight loss is assessing whether the patient has adequate donor fat to overcome severe volume loss and skin laxity. The amount of donor fat needed to achieve a pleasing shape is much greater than it seems, ranging from 450 to 1100 mL per side, depending on patient size and gluteal dimension. The ideal candidate for autologous buttock augmentation is slightly overweight, but in good health.
Implantation of gluteal prostheses is not often performed by plastic surgeons due to well-known risks that include wound dehiscence, extrusion, seroma, and infection. Furthermore, gluteal prostheses carry risks of rotation, capsular contracture, and displacement.
Suction lipectomy would exacerbate volume deficiency and result in little to no skin tightening.
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.
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 40-year-old woman comes to the office because she is dissatisfied with the “deflated” appearance of her buttocks (shown) after undergoing gastric bypass surgery, followed by a 100-lb (45-kg) weight loss. Physical examination shows skin laxity and deflation of the buttocks. In addition to performing a lower body lift, which of the following is the most appropriate management of the buttock deformity?
A) Application of external radiofrequency (Thermage)
B) Augmentation with gluteal artery perforator flap coverage
C) Fat grafting
D) Implantation of prostheses
E) Suction lipectomy
The correct response is Option B.
Gluteal changes related to loss of volume, ptosis, and skin laxity following massive weight loss require aggressive surgical techniques to improve contour and augmentation.
External radiofrequency (Thermage) does not address deflation and has shown conservative results with regard to skin tightening. It does not offer the degree of tightening that would adequately treat the massive weight-loss patient. The gluteal region in patients who have sustained massive weight loss following gastric bypass surgery is characterized by excessive skin and exaggerated fat loss. Lower body lift procedures remove excess skin and lift sagging buttock tissue, but they do not address deflation and may result in further gluteal flattening. Autologous gluteal augmentation flaps, such as those vascularized by the superior and inferior gluteal artery perforator arteries, can be transferred reliably during lower body lifts to add volume and projection to the buttocks.
Fat grafting is the most prevalent form of gluteal augmentation with the greatest safety profile, currently surpassing gluteal prostheses. The greatest challenge in using autologous fat in a patient who has sustained massive weight loss is assessing whether the patient has adequate donor fat to overcome severe volume loss and skin laxity. The amount of donor fat needed to achieve a pleasing shape is much greater than it seems, ranging from 450 to 1100 mL per side, depending on patient size and gluteal dimension. The ideal candidate for autologous buttock augmentation is slightly overweight, but in good health.
Implantation of gluteal prostheses is not often performed by plastic surgeons due to well-known risks that include wound dehiscence, extrusion, seroma, and infection. Furthermore, gluteal prostheses carry risks of rotation, capsular contracture, and displacement.
Suction lipectomy would exacerbate volume deficiency and result in little to no skin tightening.
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 65-year-old woman comes for evaluation of persistent sharp, stabbing pain in the lower abdomen that radiates to the groin. She underwent abdominoplasty 6 months ago, and the pain first occurred 1 month after the procedure. The patient says that the pain is aggravated when she walks. Weight is 154 lb (70 kg). Which of the following is the most appropriate initial step in management?
A) Electromyography and nerve conduction studies
B) Initiation of a 6-month course of gabapentin
C) MRI of the abdomen and pelvis
D) Nerve block with lidocaine
E) Surgical exploration and excision of neuroma
The correct response is Option D.
Although nerve injury is not the most common complication of abdominoplasty, it does occur in approximately 1% of patients undergoing cosmetic procedures and in 2 to 4% of patients who have similarly located Pfannenstiel incisions for obstetric and/or gynecologic procedures. Patients with symptoms of neuropathic pain after abdominoplasty are often referred for a series of diagnostic tests and consultations that may not be necessary, delaying definitive treatment.
Patients experiencing neuropathic pain after abdominoplasty have most often sustained an injury to the lateral femoral cutaneous, iliohypogastric, or ilioinguinal nerve. The typical symptom is pain that can occur immediately or develop over time. Patients usually report a stabbing pain at the corner of the incision that may radiate to the pubic area and/or upper leg. Hyperextension or ?twisting? upper body movements can aggravate the pain. If abdominal muscle contraction intensifies the pain (Carnett sign), the pain is probably located in the abdominal wall. When nerve entrapment is suspected, a nerve block using a short-acting anesthetic injected into the trigger point is the next step in diagnosis. MRI and nerve conduction studies are rarely useful in this setting. If the patient reports relief with the injection, a second block with corticosteroids may provide long-term relief. If not, a well-targeted exploration with possible neurectomy and replantation may be indicated. While treatment with gabapentin (Neurontin) may provide temporary relief, its use is poorly tolerated in the long term and does not aid in the diagnosis or the definitive treatment of the problem.
Which of the following is more likely to occur with internal ultrasound-assisted lipoplasty when compared with traditional suction-assisted lipectomy?
A) Contour deformities
B) Infection
C) Seroma
D) Skin laxity
E) Surgeon fatigue
The correct response is Option C.
Internal ultrasound-assisted lipoplasty (UAL) has been associated with an increased incidence of seroma formation, tissue damage, and thermal damage, as well as neurapraxia. With the use of a cannula or solid probe, ultrasound energy is transmitted to the fat layer, where it disrupts the fat cell. The ?liquefied? fat is then aspirated with suction. To prevent thermal injuries to the skin, infiltration of solution is mandatory, and the cannula or probe needs to be in constant motion.
Although there are unique advantages and disadvantages of each lipoplasty technique, in experienced hands, excellent results can be achieved with any of the techniques, including suction-assisted lipectomy, power-assisted lipoplasty, UAL, and laser-assisted lipoplasty. Contour deformities are related to how the operator performs the technique rather than the technique itself.
Infection rates are similar for the two procedures. Some studies have noted a decrease in both skin laxity and surgeon fatigue with UAL.
For each patient with excessive abdominal tissue, select the most appropriate surgical procedure (A €“E).
A ) Abdominoplasty
B ) Abdominoplasty and liposuction
C ) Circumferential lower body lift (hemi-body lift)
D ) Liposuction
E ) Panniculectomy
A 49-year-old woman who underwent gastric bypass surgery. She has lost 100 lb, going from a body mass index (BMI) of 45 kg/m2 to 28 kg/m2, and now has excess anterior abdominal and buttock tissue.
A 55-year-old man with a BMI of 40 kg/m2, who has had episodes of severe intertrigo and skin infections from overhanging skin and fat of the anterior abdomen. He has smoked one half of a pack of cigarettes daily for five years.
The correct response for Item 1 is Option C and for Item 2 is Option E.
For the massive weight-loss patient, only a circumferential lower body lift adequately addresses excessive tissue of both the anterior and posterior trunk.
For the patient with skin infections, a panniculectomy will address the excessive abdominal pannus, which is producing the symptoms described. In a patient with a history of smoking, there is an increased risk of wound-healing complications and skin necrosis. Other surgical options that involve undermining tissues and raising skin flaps will further jeopardize the vascularity and healing of the overlying skin. Liposuction would address the excess adipose tissue but not the excess skin. A straight panniculectomy without undermining will minimize the risk of wound complications in a patient with a history of smoking. Patients who smoke should be counseled on the importance of smoking cessation at least four weeks before and after elective surgery.
A 50-year-old woman comes to the office for consultation regarding body contouring one year after undergoing a gastric bypass procedure. She has lost 160 lb since the procedure was performed. Preoperative photographs are shown above. Which of the following is the most appropriate surgical procedure for improvement of the thigh and buttock regions in this patient?
(A) Direct excision of gluteal skin folds
(B) Suspension of a dermal fat flap
(C) Augmentation of the gluteal region
(D) Liposuction
(E) Lower body lift
The correct response is Option E.
In this patient, the best option for improvement of the buttock and thigh regions is a lower body lift. This procedure is indicated in patients with relaxation and resultant ptosis of the buttock and thigh tissues. In addition to moderate or more severe skin laxity, the potential for laxity to develop after liposuction is an indication for an excisional lifting procedure over liposuction alone. In this patient, placing the incision at the level used in the lower body lift will create a better hip contour as well as lift the descended thigh and buttock tissue. This can be combined with thigh liposuction to address any thigh lipodystrophy.
Direct excision of the gluteal fold can result in flattening of the buttocks, asymmetry, and hypertrophic scarring. Suspension of a dermal-fat flap is performed using a gluteal fold incision. Flattening of the buttocks and loss of gluteal fold definition, as well as hypertrophic scarring, can also result from this technique. Gluteal implants have the associated risks of implant extrusion, infection, and malposition. Furthermore, these three techniques do not address the primary pathology of the descent of tissue and do not restore the tissues to a more anatomic position. Liposuction can be used in the patient with good skin quality where adequate retraction is likely. However, if there is potential for skin laxity, liposuction may result in a worsening of the deformity as the tissue is deflated. Liposuction also carries a risk of worsening buttock ptosis, loss of gluteal fold definition, and contour irregularities. Liposuction can be used as an adjunct to excisional techniques.
