Cosmetic Liposuction/Abdominoplasty Flashcards
An otherwise healthy 32-year-old woman is considering liposuction. Assuming that the patient maintains her current weight, which of the following most accurately describes the anticipated changes in her body fat distribution after surgery?
A) Long-term reduction in the abdomen but eventual reaccumulation in the hips
B) Long-term reduction in the hips but eventual reaccumulation in the abdomen
C) Long-term reduction in treated areas but compensatory increase in fat in untreated areas
D) Long-term reduction in treated areas without reaccumulation in treated or untreated areas of the body
E) Short-term reduction in treated areas but eventual long-term fat reaccumulation in these areas
The correct response is Option D.
Available recent Level III evidence using prospectively collected standardized photographic measurements in patients who have undergone liposuction and/or abdominoplasty versus retrospective controls demonstrated that removal of excess fat through these methods provided long-term reduction in treated areas without fat reaccumulation in either treated or untreated areas of the body. This evidence contradicts the commonly held notion (mostly by the lay public) that removal of fat in one location leads to “return” of fat in another.
Short-term reductions of fat with reaccumulation in treated and/or untreated areas can occur if the patient does not remain calorically neutral after surgery. However, in this clinical scenario, it is mentioned that this patient has had no postoperative increase in caloric intake.
2018
A 32-year-old woman is evaluated for trunk contouring 12 months after undergoing laparoscopic gastric bypass surgery. Hypertension and sleep apnea have resolved. Current BMI is 32.7 kg/m2. She reports an 80-lb (36.2-kg) weight loss and is still actively losing weight. Which of the following is the most appropriate next step in management?
A) Complete blood cell count
B) CT scan of the abdomen
C) Panniculectomy
D) Re-evaluation in 6 months
E) Referral to psychiatry
The correct response is Option D.
In patients who have undergone gastric bypass surgery, consensus recommendations are to wait to proceed with body contouring surgery until the patient is at least 1 year from surgery. Additionally, recommendations are to wait until the patient has had a stable weight for at least 3 months and some authors advocate 6 months of weight stability. This is due to the fact that additional weight loss after surgery may result in recurrence of skin laxity. Stability of the long-term result is best achieved when there is stability of the underlying weight. Furthermore, risk of surgery increases with increasing BMI, thus waiting for the patient to achieve their lowest BMI prior to performing surgery will limit weight-associated risks. It is for these reasons that a return visit for reassessment in 6 months is the best choice as opposed to proceeding to panniculectomy at this time.
A CT scan is indicated in those patients where a physical examination is unable to rule out an abdominal wall hernia. In an otherwise asymptomatic patient from a hernia standpoint, reassessment of the physical examination once the patient has achieved a stable weight is the time to determine if there is an abdominal wall hernia that would be addressed at the time of body contouring surgery. At this point in time, the patient may have lost enough weight to adequately assess the abdominal wall for a hernia, and thus make a CT scan unnecessary.
Most post-bariatric patients will be obtaining laboratory assessments from their bariatric surgeon to assess for nutritional deficiencies and will be on supplements as indicated. After undergoing bariatric surgery, many patients have iron deficiency anemia. A complete blood count may be indicated for those who have symptoms or signs of anemia, or in whom a significant blood loss is anticipated. In relation to the body contouring surgery, this test is best undertaken once the plan to proceed with surgery is made. Again, this would occur once a stable weight has been achieved.
Many patients with weight control issues suffer from mental health pathology. A referral to a psychiatrist would be indicated in any patient who has a history of mental health issues or demonstrates signs or symptoms of psychopathology prior to embarking on post bariatric body contouring. As this patient has no medical issues noted, the routine referral to a mental health provider is not indicated.
2018
Which of the following measures reduces the risk for the most common complication in abdominoplasty?
A) Administration of preoperative intravenous antibiotics within 1 hour of incision
B) Attention to offloading pressure points and keeping upper extremities in neutral position
C) Discontinuation of NSAIDs and herbal supplements 4 weeks before surgery
D) Use of pneumatic compression devices before the induction of general anesthesia
E) Use of progressive tension sutures and drain placement
The correct response is Option E.
Seroma is the most common complication following abdominoplasty. Progressive tension sutures and/or use of drains have been shown to be effective in preventing this complication.
Use of antibiotics is intended to prevent infection. Discontinuation of NSAIDs, fish oil, and herbal supplements is intended to decrease the incidence of hematoma.
Offloading pressure points and extremities in neutral position is to decrease the incidence of neuropathies postoperatively.
Pneumatic compression devices and subcutaneous heparin and enoxaparin are intended to decrease the incidence of venous thromboembolism.
2018
A 35-year-old woman comes to the office to discuss improving the contour of her thighs. History includes gastric bypass surgery two years ago, followed by a stable 150-lb (68-kg) weight loss. Along with moderate horizontal excess skin, she has significant vertical excess skin, and a full-length vertical thighplasty is considered. This patient is at greatest risk for which of the following complications?
A) Hematoma
B) Infection
C) Labial spreading
D) Prolonged edema
E) Seroma
The correct response is Option D.
Each of the complications listed in this question has a significant occurrence with thighplasty in the massive-weight-loss population, but prolonged edema has been shown to be a particular risk factor in patients getting a full-length vertical component in their thighplasty, presumably due to circumferential compression of the low pressure lymphatic system. Labial spreading is possible but not likely.
2018
A healthy 29-year-old woman undergoes suction-assisted lipectomy with a tumescent solution for thigh lipodystrophy. A maximal dose of lidocaine 55 mg/kg is planned through the tumescent solution, and aspiration is planned through a 4-mm blunt-tipped cannula. Which of the following best approximates the expected percentage of local anesthetic in the aspirated material?
A) 20%
B) 50%
C) 70%
D) 90%
The correct response is Option A.
While there is evidence that doses of up to 55 mg/kg can be safely used in liposuction, the safe dose is likely dependent on the vascularity of the tissue injected rather than aspiration of the local anesthetic during the procedure. Studies have shown that between approximately 10 and 30% of local anesthetic is present in the aspirate, and one study showed that a mean of 9.8% of wetting solution was removed.
The knowledge that the majority of tumescent solution remains in vivo is important because lidocaine toxicity is a risk after tumescent liposuction.
2018
A 48-year-old man who underwent laparoscopic gastric bypass surgery 2 years ago is evaluated for a belt lipectomy after a massive weight loss of 150 lb (68 kg). He has maintained a stable weight for over 6 months. Current BMI is 30 kg/m2. Which of the following factors most increases the risk for hematoma in this patient?
A) Age
B) Gender
C) Location of incision
D) Postoperative BMI
The correct response is Option B.
Male gender is an increased risk factor for hematoma and seroma in body contouring patients, independent of hypertension. Age, incision site, and postoperative BMI have not been shown to increase the risk for hematoma.
2018
A 35-year-old woman, gravida 3, para 3, is interested in a “mommy makeover”, with liposuction of the flanks, extended tummy tuck, brachioplasty, and augmentation mammaplasty. In this combination of surgeries, which of the following percentages best represents the cumulative risk in the general population for postoperative complications requiring reoperation or hospitalization?
A) 3%
B) 12%
C) 25%
D) 35%
E) 50%
The correct response is Option B.
Abdominoplasty is known to have a higher complication rate than many common aesthetic procedures. A recent study by Grotting and associates examining complication rates in more than 25,000 abdominoplasties in a multi-surgeon database confirmed that the risk for a complication requiring hospitalization or reoperation increases significantly when abdominoplasty was combined with other surgeries.
In particular, abdominoplasty alone had a complication rate of 3.1%.
Abdominoplasty combined with liposuction – 3.8%
Abdominoplasty combined with a breast procedure – 4.3%
Abdominoplasty combined with a breast procedure and liposuction – 4.6%
Abdominoplasty combined with liposuction and a body contouring procedure – 10.4%
Abdominoplasty combined with liposuction, a breast procedure, and a body procedure – 12.0%
In this study, body procedures included brachioplasty, buttock lift, calf implant, labiaplasty, lower body lift, thigh lift, and upper body lifts.
Hematoma, infection, and suspected or confirmed venous thromboembolism represented 31.5%, 27.2%, and 20.2% of overall abdominoplasty complications in this study.
A second study, by the same group, looking at 129,000 cosmetic surgery patients as a group also confirmed an increased risk for major surgical site infections in cosmetic patients undergoing multiple simultaneous procedures.
Thus, caution is advised when considering multiple procedures concurrently in a higher risk patient.
2018
Which of the following is the most likely result of performing liposuction in conjunction with brachioplasty?
A) Facilitated tissue dissection
B) Lymphedema
C) Skin necrosis
D) Upper arm paresthesia
E) Wound dehiscence
The correct response is Option A.
Liposuction is often used in conjunction with excisional brachioplasty to facilitate dissection of the soft tissue, improve contour, and decrease the risks for nerve injury and lymphedema. There are many different techniques posed in the literature. Liposuction of the planned tissues of excision can ease the dissection planes. It can also be performed in the posterior upper arm to improve contour of the remaining tissues. Nerves and lymphatics are more protected by using liposuction instead of excision to debulk the arm. The use of liposuction does not increase the incidence of skin necrosis or wound dehiscence.
2018
Which of the following is the most common complication after cryolipolysis?
A) Hematoma
B) Paradoxical adipose hyperplasia
C) Seroma
D) Surface contour irregularities
E) Transient hypoesthesia
The correct response is Option E.
Cryolipolysis is a noninvasive technique to preferentially destroy adipose cells through controlled thermal reduction. Exposure of adipose cells to below normal temperatures results in apoptosis-mediated cell death. Adipose cells are more susceptible to thermal reduction as compared with adjacent tissue. The subsequent inflammatory response results in the removal of damaged adipose cells within 3 months. The most common complication following cryolipolysis is hypoesthesia or decreased sensation of the treated areas, which resolves within 6 months. Other complications, which are less common, include paradoxical adipose hyperplasia, surface contour irregularities, and chronic pain. No hematomas or seromas have been reported in the literature.
2018
A 28-year-old woman comes to the office for a consultation on liposuction of the abdomen. She has already had consultations with several other physicians and is unsure whether to undergo suction-assisted liposuction (SAL) or ultrasound-assisted liposuction (UAL). Which of the following is the most significant advantage of choosing UAL over SAL?
A) Better aesthetic outcome
B) Better skin tightening
C) Greater patient satisfaction
D) Less surgeon fatigue
E) Lower complication rates
The correct response is Option D.
The main advantage of ultrasound-assisted liposuction over suction-assisted liposuction is less surgeon fatigue.
In traditional or suction-assisted liposuction, the fat is removed by the repetitive arm movements breaking up the fat. The suction then aspirates the loosened fat. In ultrasound-assisted liposuction, ultrasound energy breaks the fat apart and emulsifies it, thus allowing it to be removed by the suction cannula. The main advantage of this is to decrease surgeon fatigue from the repetitive arm movements and also to help break apart the fat in fibrous areas or areas of scar from prior procedures.
Peer-reviewed studies have not shown any consistent evidence-based benefits for the use of ultrasound-assisted liposuction over suction-assisted liposuction. The aesthetic outcomes, patient satisfaction, and rates of long-term complications appear to be more related to technique and not technology. As a result, suction-assisted liposuction continues to remain the predominant technique of liposuction due to its relatively low cost and the rapid rate at which new technologies are introduced with little objective evidence supporting any additional benefit.
2018
A 39-year-old woman comes to the office for a consultation regarding abdominoplasty. Three years ago, she underwent gastric sleeve bariatric surgery, which was followed by a 100-lb (43-kg) weight loss. Weight has been stable for 1 year. Past medical history includes mitral valve prolapse, sleep apnea, and exercise-induced asthma. The patient is gravida 5, para 2, with 3 miscarriages. Her mother had deep vein thrombosis at 70 years of age while on a 5-hour flight. BMI is 31 kg/m2. Physical examination shows an overhanging panniculus with intertrigo. An evaluation by which of the following is the most appropriate next step?
A) Cardiologist
B) Dermatologist
C) Hematologist
D) Nutritionist
E) Sleep specialist
The correct response is Option C.
This patient presents with multiple risk factors for deep vein thrombosis (DVT). According to the 2005 Caprini Tool for DVT Risk Assessment, this patient has a minimum of 7 points (3 points for family history of thrombosis, 1 point multiple miscarriages (>3 miscarriages), 1 point for BMI > 25, and 2 points for Major Surgery > 45 minutes). With both a family history of thrombosis and multiple miscarriages, there is a significant likelihood that the patient has a genetic thrombophilia. A hematologist will be able to diagnose and quantify the significance of a genetic thrombophilia. A genetic thrombophilia such as Positive factor V Leiden gene mutation, if present, would add an additional 3 points of risk for DVT and pulmonary embolus, bringing the total risk score from 7 to 10. If abdominoplasty were performed, chemoprophylaxis would be highly recommended with these risk factors.
The mechanism of multiple miscarriages in women with thrombophilia is clotting of the placenta and subsequent fetal loss. These women are given anticoagulation chemoprophylaxis during pregnancy to help prevent placental thrombosis.
The most common inherited thrombophilia is factor V Leiden, which is present in 3 to 7% of the Caucasian population. Multiple inherited thrombophilia conditions can be present in the same individual.
Consultations with a sleep apnea specialist, cardiologist, dermatologist, and nutritionist are all reasonable considerations; however, the evaluation for genetic thrombophilia is most crucial to this patient’s evaluation for abdominoplasty.
2018
A 32-year-old woman is interested in post-pregnancy body contouring. BMI is 34 kg/m2. When combined with abdominoplasty, liposuction of which of the following areas has an increased risk for wound healing complications?
A) Flank
B) Lateral hip
C) Lateral thigh
D) Mons pubis
E) Supraumbilical abdomen
The correct response is Option E.
Traditionally, the supraumbilical abdomen has been considered the area where liposuction might further disrupt blood supply already interrupted by the abdominoplasty undermining. Techniques to minimize undermining and preserve blood supply to allow more aggressive liposuction in this area have been reported and are in use. The mons pubis, lateral hip, flank, and lateral thigh blood supplies are less affected by abdominoplasty, and therefore, these areas have traditionally been less prone to complications when liposuction is performed in them at the time of abdominoplasty.
2018
A 43-year-old woman comes to the office for consultation regarding abdominoplasty. She says she is concerned about postoperative hypoesthesia of the abdominal wall. Which of the following areas is most likely to have the greatest decrease in sensation after a traditional abdominoplasty in this patient?
A) Epigastric
B) Infraumbilical
C) Lateral abdominal
D) Mons pubis
E) Subxiphoid
The correct response is Option B.
The innervation to the anterior abdominal wall comes from the anterior cutaneous branches of the 6th to 12th intercostal nerves. The anterior cutaneous nerves perforate the anterior rectus sheath and are severed during the undermining of the abdominal flap during abdominoplasty. The hypogastric or infraumbilical region becomes the distal-most point for sensory innervation from the surrounding intact lateral cutaneous branches of the intercostal nerves that innervate the lateral anterior abdominal wall. The transverse incision from the abdominoplasty limits innervation from the pubic and thigh regions. The mons pubis should not demonstrate much change in sensation as it lies inferior to the surgical scar.
Patients undergoing abdominoplasty should be made aware of the likely decrease in sensation of this area, including superficial touch, superficial pain, pressure, vibration, and temperature.
2017
A 48-year-old woman with a history of a 160-lb (73-kg) weight loss after gastric bypass surgery comes to the office because she seeks a trimmer torso. Current BMI is 29 kg/m2. Physical examination shows excessive skin on the horizontal and vertical dimensions of the abdomen. Which of the following procedures is most likely to result in aesthetic correction of the deformity?
A) Circumferential dermolipectomy
B) Corset abdominoplasty
C) Externally applied laser lipolysis
D) Liposuction of the anterior abdomen
E) Revision of the gastric bypass
The correct response is Option B.
The increasing popularity of bariatric surgical procedures for the management of obesity has generated a plethora of plastic surgical techniques to deal with the sequelae of massive weight loss. A thorough analysis of the anatomical result of weight loss is key in determining the ideal procedure for each individual’s situation and goals. While liposuction might be helpful as an adjunct to surgical excision, it does not usually produce measurable skin tightening in this group of patients. Skin resection options have been devised based on the skin laxity pattern. When significant horizontal and vertical skin excess is present, a corset trunkplasty, devised by A.P. Moya, is the most likely of the choices to result in a trimmer abdomen shape. This option addresses the upper abdominal skin laxity that is not routinely addressed with traditional abdominoplasty. Circumferential dermolipectomy, also known as belt lipectomy, creates a vertical tightening but not a horizontal tightening of loose skin. Laser lipolysis applied externally is not indicated for the management of excessive skin laxity. This patient has achieved an acceptable result (BMI of 29) of bariatric surgery and therefore no revision of the bypass operation is indicated.
2017
A 48-year-old man is evaluated for a panniculectomy for symptomatic panniculitis 18 months status post Roux-en-Y gastric bypass. The patient has lost 150 lb (68 kg), and BMI is 28 kg/m2. He reports taking a multivitamin every day and exercising for 30 minutes three times a week. Physical examination shows no abnormalities. Preoperative nutritional evaluation will most likely show a deficiency in which of the following micronutrients?
A) Iron
B) Vitamin A
C) Vitamin B1 (thiamine)
D) Vitamin B12 (cobalamin)
E) Vitamin D
The correct response is Option A.
Because of the restrictive and malabsorptive components of the procedure, iron deficiency anemia is very common in post-bariatric patients. Iron deficiency occurs in 30 to 50% of post-bariatric patients despite a recommended daily multivitamin.
Roux-en-Y gastric bypass promotes weight loss through both a restrictive component and a malabsorptive component. This has implications for micronutrient absorption, because pancreatic release of enzymes is no longer synced with gastric emptying, and factors involved in the processing and absorption of micronutrients are decreased. Micronutrient deficiencies are common after bariatric surgery, and while many are asymptomatic, they can have effects on wound healing after surgery.
Vitamin B12 deficiencies are most common at least 12 months after surgery and range from 3.6 to 37%, but they depend on chronicity, degree of supplementation, and type of bypass. Brolin, et al, in 2002, compared patients with a distal Roux-en-Y gastric bypass to those with short Roux limbs (150 cm and 50 to 75 cm). Vitamin B12 deficiency was most common in patients who underwent Roux-en-Y gastric bypass, and B12 deficiency was most common after surgery with short limbs (50 to 75 cm). Vitamin B6 (pyridoxine) deficiency is approximately 17.6%. Vitamin B1, (thiamine), deficiency is estimated at 18.3% of post-bariatric patients. Most B complex deficiencies are asymptomatic. Vitamin B12 (riboflavin) deficiency is estimated to be 13.6% one year after bariatric surgery.
Because of the malabsorptive component of Roux-en-Y gastric bypass, fat-soluble vitamin deficiencies can also occur in the post-bariatric patient. Vitamin A deficiency can be progressive, and deficiency is estimated to be 11% one year after surgery and 69% four years after surgery. Vitamin E deficiency is relatively uncommon in post-bariatric patients who are taking supplementation.
2017
A 36-year-old woman with a BMI of 35 kg/m2 undergoes liposuction of the anterior trunk, posterior trunk, and circumferential thighs. Which of the following is the minimum volume of lipoaspirate that can be classified as “large volume” liposuction?
A) 1000 mL
B) 2500 mL
C) 5000 mL
D) 7500 mL
The correct response is Option C.
Lipoaspirate volumes over 5000 mL are what are widely considered to define “large volume” liposuction. This distinction has relevance as it relates to postoperative care. Patients undergoing “large volume” liposuction are often considered for overnight observation as an inpatient admission. The other volumes (1000 mL, 2500 mL, and 7500 mL) are not the cutoffs for consideration as “large volume” liposuction.
2017
A 28-year-old woman suffered a wound dehiscence after an abdominoplasty. History includes a 70-lb (32-kg) weight loss over the past 5 years through diet and exercise. She is angry and wants to know why the separation happened. Which of the following is the most likely contributor to the development of this complication?
A) Central rectus plication
B) Discontinuous release of tissue over the costal margins
C) Extensive undermining over the hips
D) Liposuction of the bilateral mid flanks
E) Liposuction of the central supraumbilical flap
The correct response is Option E.
Liposuction of the central supraumbilical flap may further impair blood supply to the area farthest from the remaining blood supply after undermining and is the most likely of the choices to cause wound healing complications. Extensive undermining over the hips is usually well tolerated and a component of most abdominoplasties. Central rectus plication, if too tight, may contribute to respiratory difficulty or umbilical loss due to constricted blood supply, but it is unlikely to directly relate to poor healing of the midline incisional skin and fat. Liposuction of the bilateral mid flanks (in contrast to the central supraumbilical flap) is usually well tolerated as it allows preservation of the blood supply traveling from the costal region into the flap. While wide undermining over the costal margins may promote poor wound healing of the advanced tissue at the superior aspect of the incision, tunneling or discontinuous release aimed at perforator preservation is a described technique to increase the ability to contour the upper abdomen without concomitant significant increase in wound healing complications.
2017
A 42-year-old woman comes to the clinic because of numbness of the right arm that extends from the mid arm to the medial aspect of the forearm to the wrist 5 weeks after undergoing bilateral brachioplasty. Which of the following operative techniques is most likely to decrease the risk for this numbness while adequately correcting the deformity?
A) Dissecting adjacent to the muscle fascia throughout the length of the arm
B) Dissecting deep to the muscle fascia throughout the length of the arm
C) Leaving a 1-cm cuff of fat overlying the deep fascia throughout the length of the arm
D) Performing a skin-only resection
The correct response is Option C.
The medial antebrachial cutaneous (MABC) nerve arises from the medial cord of the brachial plexus and innervates the medial arm and forearm. Distal to the axilla, the MABC nerve travels with the basilic vein. Anatomic studies have shown that the nerve penetrates the deep fascia approximately 14 cm proximal to the medial epicondyle relatively consistently. It is vulnerable during brachioplasty because of this position. The recommended technique to protect the medial antebrachial cutaneous (MABC) nerve is to leave a 1-cm cuff of fat overlying the deep fascia. A smaller cuff is inadequate to protect the nerve.
In cases where the brachioplasty dissection must extend distal to the elbow, one can minimize injury to the nerve by maintaining a dissection plane superficial to the deep brachial fascia and transitioning to the subcutaneous plane below the elbow.
A skin-only resection is unlikely to adequately correct the defect. Dissecting adjacent to, or deep to, the subcutaneous fascia places the nerve at risk because of the depth of the dissection.
2017
A healthy 40-year-old woman is scheduled for bilateral brachioplasty along with liposuction of the upper arms. Which of the following is the most common unfavorable outcome of this combined procedure?
A) Hematoma
B) Hypertrophic scar
C) Infection
D) Sensory nerve injury
E) Wound dehiscence
The correct response is Option B.
Adverse scarring is a common complication after brachioplasty and can warrant surgical revision in some cases. Liposuction of the arm with concomitant brachioplasty is a well-described and safe procedure. Along with seromas, recent studies show that hypertrophic scarring is the most common adverse outcome after this combined procedure. Other adverse outcomes such as hematoma, infection, and wound dehiscence are less frequently encountered. Sensory nerve injury, especially the medial antebrachial nerve, is possible, although it is much less likely than the incidence of hypertrophic scarring.
2017
A 35-year-old woman undergoes suction-assisted lipectomy of the bilateral arms using a tumescent technique. A total of 500 mL of aspirate is recovered. She is discharged home the same day, and returns to the emergency department 8 hours after discharge. Lidocaine toxicity is suspected. Which of the following symptoms is most likely in this patient?
A) Anisocoria
B) Petechial rash of the neck and axillae
C) Supraventricular tachycardia
D) Tachypnea
E) Tinnitus
The correct response is Option E.
Although safe doses of lidocaine in tumescent solution can reach 35 mg/kg, lidocaine toxicity is still a risk. Peak plasma levels of lidocaine, when injected into fatty tissue, occur 10 to 14 hours after infiltration.
Lidocaine toxicity symptoms include neurologic or cardiac toxicity. In the early stages, the complications are primarily neurologic, and can include slurred speech, restlessness, tinnitus, and a metallic taste, as well as numbness of the mouth. As the concentrations increase, the neurologic concentrations become more severe, and can progress to muscle twitching, seizures, and cardiac arrest. Treatment of lidocaine toxicity is supportive.
A petechial rash of the neck and axillae is a typical sign of fat embolism, and tachypnea is a typical sign of a pulmonary embolism. Anisocoria can be a benign finding, although if it is a new finding, it is suggestive of Horner syndrome or a brain aneurysm.
Supraventricular tachycardia (SVT) refers to tachycardia that occurs above or at the atrioventricular node. Paroxysmal SVT, atrial fibrillation, and Wolff-Parkinson-White syndrome are the most common forms of SVT. SVT can cause syncope and long-term cardiac damage.
2017
An overweight 36-year-old woman who underwent full abdominoplasty by another surgeon 6 months ago is referred to the office from the emergency department because of persistent pain around the right lower quadrant of the abdomen with concomitant paresthesia to the lateral thigh. The patient reports her postoperative course was unremarkable. Abdominal CT scan from the emergency department shows postsurgical changes and an 8 x 1-cm linear fluid collection subjacent to the incision. Which of the following is the most appropriate next step in management?
A) Administer oral gabapentin
B) Apply compression garment
C) Inject a local anesthetic
D) Massage the scar
E) Surgically explore the wound
The correct response is Option C.
In the absence of other postoperative findings, damage to or entrapment of the lateral femoral cutaneous nerve (LFCN) is the most likely cause of this patient’s symptoms. The LFCN exits the abdomen near the anterior superior iliac spine and is the most commonly injured nerve during abdominoplasty (incidence of 1.36%).
If a nerve injury is suspected, the diagnosis can be confirmed by injection of local anesthetic just proximal to the location of the pain or Tinel sign. Conservative treatment includes scar massage and physical therapy aimed at desensitization techniques. These nonoperative treatments can be combined with an oral anticonvulsant such as gabapentin for pain management in the short term. More severe or debilitating symptoms may warrant earlier surgical intervention. However, a local anesthetic nerve block is diagnostic and is indicated prior to either conservative or surgical treatment.
A compression garment would be neither therapeutic nor diagnostic for this patient.
2017
A 40-year-old woman comes to the office for body contouring following a 150-lb (68-kg) weight loss after undergoing laparoscopic gastric banding surgery. Medical history includes deep venous thrombosis 7 years ago while taking progestin for oral contraception. Family history includes two first-degree relatives who sustained a pulmonary embolism. Laboratory studies show the patient has a factor V Leiden coagulation disorder. Which of the following is the most likely cause of this disorder in this patient?
A) Increased levels of coagulation factor V
B) Increased resistance to activated protein C
C) Persistent antibodies to coagulation factor V
D) Protein C deficiency
E) Protein S deficiency
The correct response is Option B.
Factor V Leiden is the most prevalent hypercoagulation disorder. It is the most common genetic risk factor for venous thromboembolism.
Activated protein C, together with its co-factor protein S, inhibits the coagulation cascade by inactivating factor V and factor VIIIa. Activated protein C cleaves factor V in three sites; a mutation in the first site is known as factor V Leiden. In carriers of factor V Leiden, factor Va is inactivated approximately 10 times slower than normal.
Protein C and S deficiencies are described coagulation disorders. Lower levels of these proteins also inhibit the coagulation cascade and may be associated with warfarin-related skin necrosis and purpura fulminans in the neonatal period.
The most common cause of acquired coagulation disorders is antiphospholipid syndrome, an autoimmune disorder caused by antibodies to phospholipids. These antibodies include anticardiolipin, lupus anticoagulant and anti-beta-2-glycoprotein I.
Increased levels of coagulation factors VIII, IX and XI are associated with increased risk of thromboembolism.
2017
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.
2016
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.
2016
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
2016
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.
2016
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.
2016
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.
2016
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.
2016
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.
2016
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.
2016
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.
2016
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.
2016
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.
2014
A 48-year-old man presents with a history of 140-lb (63.5-kg) weight loss and moderate upper extremity adiposity with skin excess. Brachioplasty is performed. One week postoperatively, the patient reports numbness of the area in the image shown. Which of the following nerves is most likely affected in this patient?
A) Inferior lateral
B) Lateral antebrachial
C) Medial antebrachial
D) Posterior antebrachial
E) Posterior brachial
The correct response is Option C.
The medial antebrachial cutaneous nerve represents the sensory distribution shown in the illustration of the arm. This includes the skin of the anterior and medial surface of the forearm as far down as the palmar side of the wrist. This nerve also innervates the medial and posterior sides of the elbow area. Due to its anatomical course, the nerve may become easily injured.
The medial antebrachial cutaneous nerve originates from roots C8 and T1, and it branches from the medial cord of the brachial plexus just distal to the medial brachial cutaneous nerve and just proximal to the ulnar nerve. The nerve descends into the arm anterior and medial to the brachial artery. It lies on the ulnar side next to the biceps muscle as it runs distally. The nerve branches into an anterior and posterior branch just proximal and anterior to the medial epicondyle. The nerve provides sensation to the medial forearm and includes an anterior and a posterior branch. The posterior branch provides sensation to the resting surface of the elbow and forearm. The anterior division is expendable for graft material. Injury to this nerve during surgical procedures can lead to sensory loss and painful neuroma formation.
The adjacent sensory distribution includes:
Lateral/anterior: lateral antebrachial cutaneous nerve
Lateral/posterior: posterior antebrachial cutaneous nerve
Distal/anterior: palmar cutaneous branch of ulnar nerve
Distal/posterior: dorsal cutaneous branch of ulnar nerve
The lateral antebrachial cutaneous nerve is incorrect. It originates from C5, C6, and C7 and is the terminal part of the musculocutaneous nerve. It innervates the lateral forearm.
The inferior lateral cutaneous nerve arises from C5 and C6 and branches from the radial nerve to provide sensory and vasomotor innervation to the lower lateral aspect of the arm.
The posterior brachial cutaneous nerve arises from C5, C6, C7, and C8 and branches from the radial nerve to innervate the posterior aspect of the arm.
The posterior antebrachial nerve originates from roots C5, C6, C7, and C8 and branches from the radial nerve just distal to the posterior brachial cutaneous nerve in the axilla. It provides sensation to the posterior cutaneous aspect of the forearm.
2020
A 36-year-old woman developed numbness in the distribution identified in the picture shown. Which of the following nerves was most likely injured?
A) Lateral antebrachial
B) Medial antebrachial
C) Medial brachial
D) Posterior antebrachial
E) Posterior brachial
The correct response is Option C.
The posterior brachial nerve innervates the dorsal aspect of the upper arm. The lateral antebrachial nerve innervates the radial side of the forearm. The medial antebrachial nerve innervates the ulnar side of the forearm and medial upper arm.
The medial brachial nerve innervates the medial aspect of the upper arm between the medial antebrachial cutaneous (MABC) and intercostobrachial nerves.
The posterior antebrachial nerve innervates the lateral posterior aspect of the forearm.
2021
A 35-year-old woman presents with midline wound dehiscence with tissue necrosis 2 weeks after undergoing uneventful abdominoplasty. A photograph is shown. The patient reports that she did not stop smoking before surgery as instructed. Which of the following mechanisms has the greatest impact on delayed wound healing in this patient?
A) Decreased catecholamine production
B) Decreased leukocyte function
C) Decreased levels of hemoglobin
D) Increased fibrinogen production
E) Increased microvascular vasoconstriction
The correct response is Option E.
Cigarette smoking is a leading cause of preventable death and disability in the United States. Over the past 20 years, several studies have demonstrated an increased risk of postoperative complications following plastic surgical procedures including rhytidectomy, breast reconstruction, digital replantation, muscle flaps, and body contouring procedures.
Tobacco smoke is a complex mix of particulate matter, volatile acids, and gases. There are over 4000 different compounds in cigarette smoke, many of which are toxic, mutagenic, and carcinogenic. Tobacco-induced vasoconstriction is mediated directly and indirectly by nicotine, a colorless, odorless, and poisonous alkaloid.
Elevated cellular levels of nicotine cause direct microvascular vasoconstriction. Indirect pathways of vasoconstriction include the enhancement of thromboxane A2 and stimulation of catecholamine release. Random skin flaps, such as abdominoplasty, rhytidectomy, and mastectomy flaps, are predominantly supplied by the subdermal plexus, which is very sensitive to sympathomimetic agonists such as catecholamines.
Smoking also increases carboxyhemoglobin levels, which shifts the oxygen-hemoglobin saturation curve to the left. The net result is decreased oxygen-carrying capacity by direct competitive inhibition from carbon monoxide. Other effects caused by smoking include decreased prostaglandin I2 (prostacyclin) production, increased platelet aggregation and blood viscosity, decreased collagen production, decreased red blood cell deformability, increased fibrinogen production, and decreased leukocyte function (mediated by hydrogen cyanide). The net effect is a prothrombogenic state with impaired inflammation that also contributes to slow wound healing. Although fibrinogen production is increased and leukocyte function is reduced, the primary mechanism by which wound healing is impaired is related to the nicotine-induced vasoconstriction of the subdermal plexus.
Rhytidectomy patients who smoke are 12.5 times more likely to develop skin necrosis compared with nonsmokers. One study showed a 47.9% rate of wound healing problems in abdominoplasty patients who smoked compared with 14.8% in nonsmokers. Another large study of patients undergoing free transverse rectus abdominis musculocutaneous (TRAM) breast reconstruction showed no difference in free flap survival in those patients who smoked, but the smoking population had a significantly higher rate of mastectomy skin flap loss, abdominal donor site complications, and hernias. Active smoking is not only a risk factor for wound complications, but the overall number of cigarettes smoked in a lifetime can affect the rate of wound infections. One study showed a risk for infection of 14.3% in patients who claimed to have stopped smoking 4 weeks before their abdominoplasty compared with 1.2% of nonsmokers. This study also showed higher infection rates were associated with more years of smoking, a higher number of cigarettes smoked per day, and a higher number of estimated cigarettes smoked during a lifetime. Current recommendations for smokers who desire elective cosmetic surgery are to avoid smoking and all nicotine products for 2 to 4 weeks before and after surgery.
2022
