Esthétique 3 (body contouring) Flashcards
1
Q
Abdominal striae is evidence of what?
A
Attenuated of absent dermis
2
Q
What are the layers of the abdominal wall
A
- Skin
- Subcutaneous fat
- Scarpas
- Subscarpal fat
- Anterior rectus sheath
- Muscle (External, Internal, Transverse)
- Posterior rectus sheath
3
Q
What are the differences between the superficial and deep layers of abdominal fat
A
Superficial layer: thicker, more dense, durable and robust blood supply
Deep: less dense, most blood supply from subdermal plexus and myocutaneous perforators
4
Q
What is the arcuate line?
A
Transition point found half way between the umbilicus and symphysis pubis.
Above: distinct anterior and posterior rectus sheaths
Below: feuillet postérieur de l’oblique interne et l’aponévrose du transversalis fusionne à l’aponévrose antérieure
(il reste seulement le fascia transversalis en postérieur)
5
Q
What is the vascular supply of each Huger zone
A
Zone 1: Superior and inferior epigastric systems
Zone 2: superficial circumflex iliac and external pudendal vessels
Zone 3: intercostal, subcostal and lumbar vessels
6
Q
Describe the Huger zones of vascular supply
A
Zone 1: lateral to borders of the rectus sheath and above horizontal line drawn between the ASIS
Zone 2: below horizontal line between the ASIS down to pubic/inguinal creases
Zone 3: Lateral to zone 1 and superior to zone 2
7
Q
What nerve provides sensation to the abdomen?
A
Intercostal nerves T7 to T12
8
Q
dans quelle couche voyage les nerf cutanés à l’abdomen
A
entre muscle transverse et l’abdomen et l’oblique interne
9
Q
What nerve is most at risk of injury during abdominoplasty and how can you reduce the risk
A
A: Lateral femoral cutaneous nerve
Risk can be reduced by preserving a layer of fat over the ASIS
10
Q
What is the blood supply to the umbilicus? (4)
A
- subdermal plexus
- right and left deep inferior epigastric arteries
- ligamentum teres (vascularisation of)
- median umbilical ligament (vascularisation of)
11
Q
Name 4 characteristics of a aesthetically pleasing umbilicus
A
- superior hooding
- inferior retraction
- round or elipsoid shape
- shallow
12
Q
abdominoplastie: quelle couche de gras faut-il amincir et pourquoi
A
prioriser l’amincissement du gras sous-scarpal car a une vascularisation distincte de la peau (moins de risque de nécrose cutanée)
13
Q
Name 3 absolute contra-indications to abdominoplasty
A
- significant comorbidities
- unrealistic surgical expectations
- body dismorphic disorder
14
Q
Décrire les critères du body dismorphic disorder (BDD)
A
PRIDE
Preocupation
Repetitive behevior
Impairement/Distress
Cant be explained by something else
15
Q
Name 3 relative contraindications to abdominoplasty
A
- upper abdominal scars
- plans for future pregnancy
- hx of thromboembolic event
subcostal scars are particularly concerning - not optimal candidates for traditional abdominoplasy
16
Q
5 buts d’une abdominoplastie
A
- Aplatir les contour
- Corriger diastase des grands droits
- Réparer hernies au besoin
- Incisions basses et symétriques
- Apparence esthétique du mons pubis
17
Q
5 facteurs de complications d’une chx de body contouring
A
DB
fumeur
MWL
lipo aggressive
souminage extensif
18
Q
qu’est-ce qu’un abdomen scaphoid
A
concavité vers l’intérieur de la parois adbominale (= le but)
19
Q
List the componants of the SCIP Protocol (6)
A
- Do not use razors
- IV antibiotics 30-59mins prior to incision
- 24hrs of post-op antibiotics
- HbA1C must be <7
- Avoid intraoperative hypothermia
- Foley must be removed within 24hrs
20
Q
How much space must be left between the incision and vulvar commisure
A
5cm
21
Q
What are 3 clinical signs of injury to the lateral femoral cutaneous nerve
A
- significant pain
- numbness
- dysesthesia of hip and lateral thigh
22
Q
What is the incidence of LFC nerve injury in abdominoplasty procedures
A
10%
23
Q
Qu’est-ce qu’une lipoabdominoplastie et quel est son avantage principal
A
Moins souminer sur les côtés (faire de la liposuccion à la place)
Préserve davantage de vascularisation de la parois abdo (80% vs 30% avec lipec traditionnelle)
24
Q
position idéale de l’ombilic
A
ligne connectant le rebord supérieur des crêtes iliaque, croisant une autre ligne reliant l’apophyse xiphoide et le pubis
25
In which patients would you perform a miniabdominoplasty
Patients with primarily an excess of ISOLATED infra-umbilical skin and fat
26
How does the umbilicus move in a miniabdominoplasty
2 cm inferiorly
27
Name 4 ways in which the mini-abdominoplasty is different from the traditional abdominoplasty
1. Shorter scar (12-16cm)
2. Umbilicus remains attached
3. More conservative resection of skin and fat
4. Liposuction is needed to address the supra-umbilical region
28
Indication principale d'un high lateral tension abdominoplasty
Excès de peau vertical en infra-ombilical et horizontal en épigastrique
29
high lateral tension abdominoplasty: quel est le vecteur de traction
oblique
30
high lateral tension abdominoplasty:
1 avantage principal et 1 inconvénient
(+) permet aussi lift des cuisses antéro-latérales,
moins de souminage (limité à central)
(-) cicatrices plus longues et plus hautes
31
high lateral tension abdominoplasty: élément clef du marking
en central, l'incision va SOUS l'ombilic, en latéral, l'incision doit aller plus HAUT que l'ombilic
*ombilic peut être transposé
32
lipectomie circonférentielle: pourquoi ne pas trop souminer au-niveau du dos
car risque élevé de sérome
33
Why does epigastrium skin develop horizontal laxity?
Strong superficial fascial attachements to the linea alba, which limits the vertical descent of the skin
34
What are the subcutaneous fat layers et dans laquelle tu liposuccionne
- subcutaneous fat (dense and adherent)
- intermediate fat (safest layer)
- deep fat (loose and less compact)
35
What are the zones of adherence in liposuction that must be preserved
- distal iliotibial tract
- gluteal crease
- lateral gluteal depression
- middle medial thigh
- distal posterior thigh
36
physique de la liposucicon: qu'est-ce qu'un torr
un torr est la pression nécessaire pour supporter une colonne de mercure de 1mm de hauteur à 0 degrés et à gravité standard
37
décrire la relation entre la résistance et le rayon
la résistance augmente plus le rayon est grand
38
% de la solution d'infiltration qui est retiré durant la lipossucion
30% est retiré, donc 70% va être absorbé
39
5 buts d'infiltrer avant la liposuccion
Remplacement de volume
Hémostase
Contrôle de la douleur
Délimiter les plans
Dissiper la chaleur dans une UAL
40
3 syndromes prédisposants à l'obésités
Prader-Willis
Bardet-Biedl
X fragile
41
nommer les composants du lactate ringer
Na, Cl, K, Ca, lactates
42
Comment vérifier la progression de ta liposuccion
pinch test
43
Name and describe the 2 types of cellulite
Cellulite of adiposity (primary) - thérorie de Illouz
- hypertrophic fat cells in the superficial layer
- present when supine and erect
- not improved with skin tightning
Cellulite of laxity (secondary)- théorie de Lockwood
- increased skin and superficial fascia laxity
- only present when erect
- can be treated with tightning
44
Name 5 agents that should be avoided when undergoing lipocuccion
- Aspirin
- NSAIDs
- St. John Wort
- Vitamin E
- Anticoagulants
45
When should you consider pre-operative CBC in patients undergoing liposuccion
Patients undergoing large volume liposuccion (>5L)
46
Name 5 things you can do to mitigate hypothermia in patients undergoing liposuccion
- forced air warming blankets
- cover exposed body areas
- use of warm IV fluids
- increase OR temperature
- use warm wetting solution
47
Name 2 incisions that can be used for male breast liposuccion
- anterior axillary fold
- periareolar
48
Name 2 incisions that can be used for abdomen liposuccion
- lateral lower abdomen
- supra-pubic
- umbilical
49
Name 2 incisions that can be used for bottox liposuccion
- sacral
- midaxillary line in panty line
50
Name 2 incisions that can be used for medial thigh liposuccion
- medial groin crease
- inguinal crease
51
Name 2 incisions that can be used for upper arm liposuccion
- anterior axillary fold
- posterior axillary fold
- olecranon radial elbow crease
52
What are the components of Klein Solution
- 1000ml NS
- 50ml lidocaine 1%
- 1ml of 1:1000 epinephrine
- 12.5 ml of 8.4% bicarb
53
Describe the wetting solutions and the estimated blood loss
Dry : None : 20-40%
Wet : 200-300ml per area : 4-30%
Superwet : 1ml infiltrate for 1ml aspirate : <1%
Tumescent: 2-3ml infiltrate for 1ml aspirate : <1%
## Footnote
tumescent: infiltrer jusqu'à turgescence
54
How long is analgesia provided with wetting solution
18hrs
55
What is the maximum dose of lidocaine that can be used for tumescence
35mg/kg
56
In which circumstances should lipoccusion patients be kept in hospital
>5L or 6hrs of surgery
57
Why is the use of high quantities of lidocaine possible when performing tumescence
- diluted solution
- slow infiltration
- vasoconstriction of epinephrine
- relative avascularity of fatty layer
- high lipid solubility of lidocaine
- compression of vessels by infiltrate
58
quand est le peak de la toxicité d'une solution tumescente
12-14h
59
Name 2 instances where UAL would be better than SAL
- cutaneous laxity (causes theoretical tightning)
- fibrous areas (ie. gynecomastia, flanks, back)
- secondary liposuccion
60
What are the stages of UAL
Stage 1: subcutaneous infiltration of wetting solution
Stage 2: ultrasound to emulsify the fat (superficiel to deep)
Stage 3: evacuation of fat and final contouring with SAL
61
Name 3 complications specific to UAL
- thermal injury
- seroma
- hyperpigmentation
62
What is the mechanism of action in laser assisted liposuccion
The laser disrupts cell membranes and emulsifies the fat by photothermolysis
63
What is the mechanism of action of UAL (pourquoi ca émulsifie les graisse)
Crystals in the probe convert electric energy into high frequency sound waves that created cavities and cellular fragmentation (cavitation)
Micromécanique: trauma directe
Thermique: friction +chaleur absorbée par les ultrasons produits
Cavitation
## Footnote
Les cristaux de la sonde convertissent l'énergie électrique en ondes sonores à haute fréquence qui créent des cavités et une fragmentation cellulaire
64
What are the primary and secondary endpoints of SAL/PAL
Primary
- final contour
- symmetrical pinch test
Secondary
- treatment time
- treatment volume
65
What are the primary and secondary endpoints of UAL
Primary
- loss of tissue resistance
- blood aspirate
Secondary
- treatment time
- treatment volume
66
Name 6 complications of lipocussion
- Asymétry
- Séroma
- Hématoma
- Dissatisfaction
- Visceral perforation
- DVT, PE , Sepsis, necrotizing fasciitis, lidocaine toxicity
67
How do you manage lidocaine toxicity
Infuse 20% lipid emulsion
- Bolus 1.5ml/kg IV over 1 minute
- continuous 0.25ml/kg/minute
- continue infiltration over at least 10 minutes after circulatory stability
*if blood pressure still low, double continuous infusion rate
68
What is SAFElipo
Non-thermal liposuction technique that includes redcution, equalization and augmentation. More aggressive treatment that uses angled canulas
*angled canulas only used in SAFElipo*
69
Classifier les différents grade d'obésité
Embonpoint IMC >25
Obésité IMC > 30kg/m2
Obésité sévère IMC > 35
Obésité morbide IMD > 40
Superobèse > 50
70
- Excès cutanés sont circonférentiels
- Liposuccion ne peut pas être seule modalité
- Déficit nutritionnel à optimiser
71
What are the goals of trunc lipectomy in MWL
- flatten contour
- tighten abdominal wall
- repari vental hernias
- elevate mons pubis
72
What are the goals of reconstruction for the back in MWL
- resect as many rolls as possible
- create flat contour to the back
73
What are the goals of reconstruction in medial thigh lift in MWL (2)
- restore flap contour to the medial thigh
- minimize labial spreading
74
What are the goals of reconstruction for the buttock in MWL
- define the buttock (créer une démarcation avec le dos)
- elevate the buttock
- cover coccyx with additional soft tissue
75
What are the goals of reconstruction for the arms in MWL
- eliminate horizontal upper arm excess
- eliminate lateral thoracic skin excess
- smooth contour from lateral chest onto upper arm
- reduce scar visibility and contractures
76
2 indications de chirurgie bariatrique
IMC >40
IMC >35 avec commorbidités
77
What are the 2 types of bariatric surgery
- Restrictive
- Malabsorptive
78
What are the sub-procedures for each type of bariatric surgery
Restrictive (stomach only)
- vertical banded gastroplasty
- laparoscopic adjustable gastic band
- gastric sleeve
- obera weight loss baloon
Malabsoptive
- Biliopancreatic diversion (BPD)
- BPD with duaodenal switch
- Roux-Y bypass
79
What would be the prefered operating sequence in patients with MWL
1. Trunk, abdomen, Buttock and lower thigh
2. Upper thorax, breast, arms
3. Medial thighs
4. Facial rejuvination
80
What is the incidence of DVT in MWL patients
<0.1%
81
What are your criteria for patient to be okay to undergoe MWL surgery
- stable weight for past 6 months
- 12-18 months post bypass
- no metabolic or nutritional deficiencies
- ideal BMI 25-30
82
5 stratégies pour prévenir complications d'une chx de bodycontouring
- positionnement adéquat
- padding
- prévenir hypothermie
- prophylaxie antithromboque
- atb IV 30 min avant incision
83
What are the common nutritional deficiencies seen in bariatric patients (6)
- iron deficiency anemia
- Vitamin B12
- calcium
- potassium
- zinc
- Fat soluble vitamins (A,D,E,K)
- protein deficiency
84
What preoperative workup is required for MWL patients
- CBC
- Electrolytes
- Creat, BUN
- Uric acid
- Liver function
- HbA1c
- ferretin
- proteins (albumin, prealbumin)
- PT/PTT
- fat soluble vitamins
85
What is the differences between lower body lift and belt lipectomy (5)
86
What can be used as a sclerosing agent for seroma in postop MWL surgery
Doxycycline
87
List potential complications of abdominoplasty (6)
Local (minor)
- hematoma
- seroma
- wound infection
- fat necrosis
- wound dehiscence
- standing cutaneous deformity
Systemic (major)
- DVT
- PE
- abdominal compartment
- systemic infection
88
List the different interventions that can be done to address the abdomen (5)
- liposuction
- traditional abdominoplasty
- lipoabdominoplastie
- mini-abdominoplasty
- fleur de lys abdominoplasty
- reverse abdominoplasty
- high lateral tension abdominoplasty
- lipectomie circonférentielle
89
What are the 2 tests that can be used to assess myofascial laxity
Diver test: patient stands and flexes at the waist. Si plus de fullness de l'abdomen inférieur lorsque penché = signe de laxité myofascial
Pinch test: patient mettre l'adbomen sous tension. Si fullness diminue = signe de laxité myofasciale
90
comment évaluer une diastase des grands droits
-palpation lorsque couchée
-fullness du upper abdomen qui s'améliore lorsque patient est couché. SI reste rond = gras intra-abdo et non diasthase
91
2 éléments clefs de votre technique de réparation d'un diastase des grands droits
Utiliser sutures non-résorbable
Débuter à l'apophyse xiphoide (pour éviter buldge épigastre)
92
What should be administered in a patient undergoing abdominoplasty that has a Caprini score >8
Enoxaparin 40mg s/c the night before and 7 days postop (NEED TO FIND RESSOURCE FOR THIS)
93
Where is the TAP bloc done
Bloc between internal oblique and transversals muscle
94
What are advantages (2) and disadvantages (3) of progressive tension sutures
Advantage
- reduces seroma formation
- diminue tension sur la plaie
Disadvantage
- increases risk of needing revision
- low margin for error
- time consuming
95
Name the 3 fascias of the arm
- Fascia superficiel
- Fascia investissant du muscle
- Fascia clavico-pectoral
96
What 2 cutaneous nerves are at risk during brachioplasty
- intercostal brachial qui rejoint le MBC au bras
- MABC (becomes superficial 14cm proximal to medial epicondyle)
97
What are the absolute contra-indications to brachioplasty (3)
- lympheodema of the arms
- CRPS
- unrealistic patient expectations
Relatif:
- neurological or vascular disorders of the upper extremity
- collagen disorders (ie. Ehlers-Danlos, progeria)
- PAR avancée
- perte de poids instable
98
List 3 relative contra-indications for brachioplasty
- severe comorbidity (ie. heart disease, thromboembolic)
- unstable weight gain/loss
- active smoker
- history of keloid of HTS
99
What should you do intra-op if you injure the MABC during brachioplasty
- crush
- cauterize
- burry in the muscle
100
Name 2 advantages of liposuccion in brachioplasty
- large ressection possible
- bulk reduction
101
What important intra-op step must be done in mini-brachioplasties
suspention of the superficial fascia to the claviculo-pectoral fascia with permanant suture
102
What is the difference between the anterior and posterior scar in brachioplasty
Anterior
- less visible
- more hypertrophic (poor dermal quality)
Posterior
- more visible
- less hypertrophic
103
What is the complication rate in brachioplasty
40%
104
brachioplastie: où mettre la cicatrice
postérieure au sillon bicipital
*incision sinusoidale pour diminuer les risques de contracture
105
décrire la classification du upper arm contouring
Type 1: excès de gras prédominent
Type 2: laxité prédominante
A: bras proximal
B: laxité tout le bras
C: laxité ad thorax latéral
* faire extended brachioplasty
Type 3: excès gras et peau
A: bras proximal
B: laxité tout le bras
2C: bras et thorax
* lipo + lipec
106
Nommer différente techique de brachioplastie (4)
Minibrachioplastie
Brachioplastie standard
Avulsion brachioplasty
Extended brachioplasty
107
position pour faire le marking d'une brachioplastie
épaule 90d ABD
coude à 90d flexion
108
qu'est-ce qu'une avulsion brachioplastie
faire de la liposuccion agressive de la région avant de la réséquer
109
What are the limits of the femoral triangle
Superior : inguinal ligament
Inferior: adductor longus
Lateral: Sartorius
110
What is the content of the femoral triangle
Femoral artery, vein and nerve
111
Name 4 contraindications to thigh lift
- modifiable risk factors (residual obesity)
- unrealistic expectations
- unwillingness to accept lengthy scar
- DVT
- MWL with unstable chronic illness
112
What important intra-operative consideration must be done in horizontal tigh lift
anchoring of superficial fascia to Colles fascia on perineum
113
What 2 techniques to prevent ptosis reccurence
- anchoring of superficial fascia to colles fascia
- plication of gracillis and adductor longus fascia (suspension fascio-fasciale)
*these are not needed in vertical lifts*
114
List complications of thigh lift (6)
- seroma
- lymphoceles
- hematoma
- delayed wound healing
- scar migration
- prolongiued pain
- swelling
- change in shape of genital region
- leg swelling (lymphedema)
- DVT/PE
115
Describe the Felicio classification
Labia minora enlargement
1 : <2cm
2: 2-4cm
3: 4-6cm
4: >6cm
116
Name 3 options for reduction of the labia minora
- edge excision
- central wedge resection
- posterior wedge resection
- W-plasty
- central de-epithelialisation
- laser excision
117
What are the goals of labia minora reduction
- reduction of hypertrophic labia
- limit skin redundancy
- obtain adequate colour match/contour
- preservation of introitus
- maintenance of n.vasc supply
- preserve sensitivity to labium
118
List both acute and chronic complications of labiaplasty
Acute
- infection
- hematoma
- dehiscence
- transient dyspareunia
Chronic
- Asymetry
- Clitoral exposition
- Fistula
- Delayed wound healing
119
What are the goals of reconstruction in labiaplasty of the labia majora
- reduce excess redundancy
- reduce fat volume
- enhance contour
- augment atrophy
120
What are the goals of correction for the hood of the clitoris
- reduce skin excess
- relase entrapment
- resuspend to the pubic symphysis
121
Name 3 key considerations when performing SAL
- slower stroke rate to allow for cavitation
- probe must be moving at all times
- endpoint = loss of resistance
- dry technique should NEVER be used
122
What are the advantages and disadvantages of PAL
Advantages
- decreased surgeon fatigue
- larger volumes
- short procedure time
- bien pour les zones fibreuses
Disadvantages
- operator discomfort from vibration
- noise generation
- equipment cost
123
What are advantages (3) and disadvantages (5) of LAL
Advantages
- decreased intraoperative blood loss
- decreased postop ecchymosis
- possible skin tightning
Disadvantages
- potential thermal injury
- equipement cost
- increased scarring of adipose tissue
- besoin d'une 2e personne qui regarde la température
- toxicité foie/rein
124
4 étapes du LAL + type de laser utilisé
Infiltration
Application d'énergie aux tissus
Évacuation
Stimulation de la peau
NdYag: 1064
125
What is particular about water-assisted liposucction
Can be done in the office under local
126
Describe water-assisted liposuction
Dual purpose canula that emits jets of wetting solution with simultaneous suctioning of the fatty tissue and fluid
127
What are the advantages and disadvantages of WAL
Advantages
- reduced pain for patient
- decreased need for GA
- patient awake and can change positions
Disadvantages
- equipment cost
- prolongued procedure time
128
What are the stages of the WAL technique
Stage 1:Subcutaneous pre-infiltration with wetting solution
Stage 2: infiltration of rinsing solution and aspiration
129
List the different types of liposuction techniques
- SAL (suction assisted)
- LAL (laser assisted)
- PAL (power assisted)
- WAL (water assisted)
- RFAL (radio-frequency assisted)
130
What are the steps in SAFElipo
1. Step 1- Seperation: emulsify and liquify adipose tissue
2. Step 2- Aspiration: multiport, non-expanded blunt canula with suction
3. Step 3- Fat equalization: expanded tip, mutiwinged canula without suction
131
4 principes du SAFE lipo
* optimise le retrait du gras
* préserve l'intégrité vasculaire
* minimse rétraction cutanée
* minimise les revisions nécessaire
132
What are advantages and disadvantages of SAFElipo
Advantages
- reduced contour deformities
- enhanced skin tightning
- decreased ecchymosis
- wider areas of treatment
- enhanced precision
Disadvantages
- increased OR time needed
133
How long does it take for 1L of isotonic fluid to be absorbed from the interstitium
167 minutes
134
décrire votre réanimation liquidienne pendant une liposuccion
- Crystalloid IV at maintenance rate (adjust to urine output and vital signs)
- sonde urinaire si >5L prévu de lipo
- Replacement IV of 0.25 ml/ml of aspirate over 5 L
## Footnote
considérer que 70% de l'infiltration va être absorbé
135
Why is superwet preffered over tumescence technique
They have equivalant blood loss but superwet has a decreased postential for volume overload and congestive heart failiure
136
What is the end point of infiltration when performing liposuction
uniform blanching and skin turgor
137
What is the minimum amount of time you should allow to take advantage of maximal vasoconstriction of epi
7-10 minutes
138
What structures do you need to be careful for when performing arm liposuction
- basilic vein
- MABC
## Footnote
Laisser du gras sur fascia profond à la jct tiers moyen et inférieur du bras pour protéger MABC
139
Describe the healing course after liposuction
Day 1-3: Incisions drain
Day 3-5: Edema peaks and drainage slows down
Week 4-6: Edema resolves
Week 8-10: induration in large volume areas
Month 3-6: Final aesthetic result
140
What is the recommended upper limit for lipid emulsion
10-12ml/kg over the 1st 30 minutes
141
What is a key consideration that must be taken when performing brachioplasty to avoid injury to muscles and important neurovasc structures
Deep fascia layer should never be violated
142
What is the most catastrophic complication related to brachioplasty
- overresection and inability to close the wound
143
In the event that you accidently over-ressect skin during brachioplasty, what can you do (2)
- liposuction to debulk the remaining arm
- STSG using the overesected tissue as donor site
144
What should you do is the incision crosses the axilla
Add z-plasty to prevent contracture over the axilla
145
In which patients is liposuction alone adequate when treating the arms
Type 1 arms
(minimal skin excess and moderate fat excess)
146
Where should avoid placing your incision in brachioplasty and why
Medial epicondyle due to ulnar nerve injury risk
147
What is the most common complication after brachioplasty
wide, unsightly scars
148
Name 5 common complications of brachioplasty
- wound dehiscence
- HTS
- infection
- Seroma
- Paresthesia
- tethering across axilla
- reccurent skin laxity
149
What is the most common complication in brachioplasty not related to scarring
seroma
150
List the 4 major methods for buttock augmentation
- autologous fat grafting
- silicone implants
- autologous flap augmentation (specially in MWL)
- agent de comblement
151
nommer des exemples de lambeaux local pour auto-augmentation des fesses + complication la plus fréquente associées
Dermal fat flap
SGA perforator flap
Split gluteal muscle flap
Island fat flap
Purse-string gluteoplasty
Complication la plus fréquente: déhiscence de plaie
## Footnote
Janis 2022
152
How do you decide between autologous and fat in buttock augmentation
Based on the amount of fat available. If enough fat, should go with fat grafting
153
What are the contraindications to buttock augmentation
- pregnancy
- neoplasm
- severe comorbidity
154
What is the ideal shape of the inner gluteal fold in buttock augmentation
diamond shape
155
nommer les 4 types de forme de fesse
Carré 40%
A-shape (poire) 30%
V-shape (pomme) 30%
Rond: 15%
## Footnote
ligne créee selon 3 points:
-upper lateral hip
-lateral thigh
-lateral mid-buttock
156
décrire les caractéristiques d'une fesse idéale
- légèrement convexe
- légère dépression latérale (femme)
- courbure lombaire de 45d
- creux au niveau du V pré-sacré
- Absence de ptose
- Fossette supra-glutéales visibles (dimple of venus)
- waist to hip ratio de 0,7
157
What is the amount of fat needed for autologous fat grafting in buttock augmentation
450-1800cc per side
## Footnote
non indiqué si IMC < 20 ou > 30
158
List complications specific to implant based buttock augmentation (4)
- extrusion
- displacement
- capsular contracture
- implant exposure
159
What are the 4 possible planes where silicone implants can be inserted for buttock augmentation
- subcutaneous
- submuscular
- intramuscular
-subfascial
160
What is at risk when performing submuscular buttock implants
sciatic nerve injury
161
What clinical signs would raise your suspicison for fat embolus syndrome or macroscopic fat emboli in a patient who has just underwent buttock augmentation via fat grafting
- confusion
- petechiae
- fever
- respiratory distress
162
List ways to reduce the risk of fat embolus syndrome in patients undergoing buttock augmentation
- keep injection cannula parallel to patient (pas anguler downward)
- subcutaneous injection
- cannule >4mm à un seul trou
- avoid excess volume injection
- injecter tjrs en mouvement
163
indication d'augmentation glutéale par implant
patient a peu d'excès adipeux
164
décrire 2 mécanisme d'embolie graisseuse suite à un BBL
1. Canulation directe d'un vaisseaux en injectant
2. Injecter sous fascial entraine acculation de gras en espace sous-musculaire, ce qui augmente la pression, entraine traction sur les veines et ''siphon effect'' qui va amener gras dans la circulation veineuse
165
décès associé au BBL
1:3000 (ad 1:6000)
166
What vessel is usually involved in fat embolus syndrome
Inferior gluteal vein
167
What factors increase the risk of fat emboli syndrome
- increased volumes
- intramuscular injections
- injection near piriformis (gluteal vessels)
168
What is the significance of scars in abdominoplasty planning (upper midline and subcostal)
upper midline: limit inferior movement of abdominal skin flap
subcostal: represent interruption of superolateral blood supply. Highest risk of complications
169
What important information about striae must be shared with patients when consenting for abdominoplasty
Aboce umbilicus, striae will not be removed and may become more prominent
170
In which percentage of the population is the umbilicus truely midline
1.7%
171
What is particular about the fleur de lys technique (2)
excision of BOTH lower abdominal skin and fat and supraumbilical horizontal excess
ne pas souminer au-delà de la zone à exciser
172
What is a reverse abdominoplasty
Technique that allows for removal of isolated supraumbilical/epigastric excess through a transverse upper abdominal incision
173
At which level is the incision made in reverse abdominoplasty
IMF
174
What complications of skin redundancy can be seen in MWL patients (4)
- skin infections/rashes
- MSK pain
- déficit fonctionnel (ambulation, urination, sexual function)
- psychological distress (depression, self-esteem)
175
In which direction is the thigh excess skin in MWL (a) and in which direction will you perform the lift (b)
a) horizontal
b) vertical
176
How can you reduce the potential for labial spreading in medial thigh lift (1)
Do not place tension on horizontal scar
177
Name 3 contraindications to medial thigh lift
- preexisting lymphedema
- lower extremity dVT
- presence of varicose veins (need to obliterate them prior to surgery)
178
What structure should be preserved during resection in the medial thigh lift
Saphenous vein
179
Name 4 characteristics of the MWL breast
- poor shape and skin elasticity
- severe ptosis and volume loss
- flattening of breast
- distorted nipples (infero-medially translocated)
180
List 3 particularities about rhytidectomy in the MWL patient
- requires more **undermining** to acheive smooth contour
- more agressive **skin resection** is required
- **midline skin incision **in the neck should be considered if redundancy to significant for lateral pull
181
What body temperature should be aimed during body contouring procedures
>35oC
182
What intraoperative fluid rate will you give your patient during MWL body contouring procedure
maintenance fluid + 10ml/kg/hr
183
MWL: pourquoi stager les procédures diminuent le risque de complications
- Diminue le temps d'anesthésie
- Moins de perte sanguine
- Diminue vecteurs de traction opposés
- Permet faire chx révision lors des autres procédures
- Favorise la mobilisation post-op si pas plein de sites opérés
184
What percentage of MWL patients are anemic
50%
185
Name 4 ways to reduce the risk of DVT/PE in MWL patients
- heparine or LMWH before surgery and during hospitalization
- epidural analgesia
- sequential compression devices
- Early ambulation (day of surgery)
- Incentive spirometry
186
What can be done to manage lymphocele in MWL patient. (3)
- serial aspirations
- doxycycline injection
- percutaneous drainage with closed suction drain
- operative exploration and ligation of lymphatics
187
List 4 factors that increase the risk of wound complications in MWL patients
- Tobacco
- Diabetes
- Systemic steroid use
- BMI >40
188
Where is the femoral triangle in relationship to colle fascia
Lateral to it
189
Where does Colles fascias attach
- ishiopubic rami of bony pelvis
- scarpas of the abdominal wall
- posterior border of urogenital diaphragm
190
cuisses: How is skin laxity in the upper 1/3rd treated
medial thighplasty (crescent tighplasty)
191
How can you treat laxity to middle third
short-scar vertical thighplasty
192
How can laxity of entire thigh be treated
Full length vertical thighplasty
193
What should be your dissection plane in medial thigh lift
deep to the superficial fascia to avoid great saphenous vein
194
What is particular about the fascio-fascial suspension technique in medial thigh lift
tension of the thigh lift is on the overlap of gracilis and adductor longue instead of Colles fascia
195
Describe the ideal traits of the female external genitalia
- labia minora does not protrude past the labia majora when standing
- Labia majora conceals the labia minora with minimal bulkiness
- inconscipuous clitoral hood
- mons fat pad does not protrude in clothing
196
Name 4 causes of labia minora enlargement
- Congenital (most common)
- Pregnancy
- OCP
- Topical estrogen
- Vulvar lymphedema
- Dermatitis 2o to incontinence
197
What is the most common reason why patients seek revision surgery after labiaplasty
Hood redundancy
198
When addressing labia with clitoral hood which should be done first
a) labia before hood
199
When addressing the labia majora resection with the a) labia minora and b) the pubis, which should be done first?
a) minora before majora
b) pubic lift before majora
200
What is the most common complication associated with labioplasty
Wound dehiscence
201
How long should you wait before doing a revision following labiaplasty
minimum 4 months
202
List 4 effects of fat grafting on irradiated skin
- decrease collagen deposition
- attenuates thickened epidermis
- improves hyperpigmentation
- diminishes vascular density
## Footnote
dowregulation de la réponse fibrotique de la radiation
203
nommer 2 deux fractions cellulaires obtenues d'un lipoaspirat
stromal vascular fraction (SVF)
Adipose tissue-derived stem cell (ASCs)
204
What are the 3 layers of the harvested fat after centrifugation
**Upper layer**
Oil from ruptured fat cells
**Middle layer**
Adipose tissue
(most viable at the bottom of this zone)
**Lower**
Blood
Water
Lidocaine
si demande 4e: SVF au plus bas
## Footnote
on décante la couche supérieure avec un coton, et on laisse drainer la inférieure via ouverture de la seringue
205
pourquoi faut-il minimiser le contact avec l'air des cellules adipeuses centrifugées?
## Footnote
mais peut-être aussi juste overall peut-importe ton processus de refinement
entraine dessication des lyse des cellules adipeuse
206
What are the 2 theories of fat grafting
1) Cellular replacement theory (histocytes replace fat)
2) Fat cell survival theory
207
List 4 advantages and 3 disadvantages of fat grafting
Advantages
- safe
- innexpensive
- soft tissue contouring of donor
- low donor morbidity
- readily available
- natural appearance
Disadvantages
- resorption unpredictable
- results highly technique dependend
- volume will fluctuate with weight changes
208
Describe the Coleman technique
- manual harvest
- 3 mm diameter, 17-gauge lumen, 15 or 23 cm length, blunt tip
- infiltration 1:1 wetting solution
- Luer-Lok to prevent leakage
209
What does fat sticking on the Codman neuropad indicate?
Fat has been exposed to the air too long and should be discarded
210
What dictates the level of fat placement in fat grafting and where should you place it
a) dictated by the goal
strenghten soft tissue: deep against bone or cartillahge
support skin for aesthetic appearsance: immediately under the skin
fill, plump or restore fullness: internediate between skin and underlyigng tissues
211
Describe 3 cannula types for fat grafting
v-dissector: used for correction of scars
type 1: completely capped on the tip (minimizes injury to nerves, vessels, etc)
type 2: not completely capped ont he tip
Type 3 : flat on the end, allows dissection through tissue
212
What is the most common problem following fat grafting
edema postop
213
What can be done to treat/prevent edema following fat grafting
- elevation and cold therapy ad 48hrs postop
- microfoam tape for 3-4 days
- pressure during sleep
- massage DONOR site as soon as possible
** do not massage recipient for min 2weeks*
214
What are the 3 histologial zones of grafted fat
Peripheral zone (viable adipocytes)
Intermediate zone (inflammatory cells)
Central zone (necrosis)
215
5 facon d'augmenter la viabilité de la lipogreffe
* PRP (dim reaction inflam, dim formation kystes huileux)
* Ajouter le stromal vascular fraction à l'aspirat
* Récolter à faible pression d'aspiration
* Maintenir aspirat dans un système fermé
* Prioriser washing plutôt que centriguger
* injecter à basse vitesse (max 1cc par sec)
216
5 principes de lipogreffe concernant l'injection
* injecter dans directions différentes
* injecter dans plans différents
* injecter tjrs en mouvement
* injecter à basse vitesse
* injecter avec petite seringue (précision)
217
après combien de temps le résultat d'une lipogreffe est-il permanent
6 mois
218
Name 4 ways to prepare harvested fat
- centrifugation
- sedimentation
- washing
- gauze-roling
## Footnote
washing = NS, glucose 5%, LR ou eau stérile
sédimentation = décanter pendant 1h
219
List 3 washing solution options in fat grafting
- NS
- 5% dextrose
- RL
- Sterile water
220
Which is the least traumatic method to prepare fat cells after fat harvest
sedimentation/straining
221
How long after harvest do fat cells begin to degenerate
4hrs
222
What is the limitting step in fat grafting
O2 diffusion
223
What are the 5 rules of fat grafting
- no infection without movement
- injection/movement <0.1cc/cm
- small seringe
- never 2 movements in the same direction
- precision
224
What is the optimal thickness of the regeneration zone
1.6mm
225
6 indications de lipogreffe dans le sein
Poland
Micromastie
Sein tubéreux
Irrégularité post reconstruction
Déformité après radiotx
NAC recon
226
Nommer les 3 plans d'infiltration du fat grafting pour une augmentation mammaire primaire
Sous-cutané
Pré-pectoral
Intramusculaire
## Footnote
on injecte pas directement dans le parenchyme
227
bénéfice de la lipogreffe en radiothérapie
peau irradiée devient plus douce et souple
aide à la résolution de l'ulcération
améliore l'indice cicatriciel
## Footnote
faire lipogrreffe immédiatement après radiotx c'est mieux pendant que les tissus sont encore inflammés
228
bénéfice de la lipogreffe pour les nerfs
Aide à la dlr liée aux névromes
Aide à la regénération nerveuse
229
5 indications/utilité de la lipogreffe au visage
* Augmentation malaire
* Dépression des cicatrices d'acnée
* Rejuvénation péri-orbitaire
* Augmentation des lèvre
* Lipoatrohpie (age, vih, drogue)
230
2 utilité de lipogreffe aux main
* avec fasciectomie Dupuytren
* Rajeunissement du dorsum
231
expliquer ce qu'est le PALF
Percutanous aponeurotomy and lipofilling: alternative dans le traitement des contractures de cicatrice
232
List 9 complications specific to fat grafting
- fat resorption
- fat necrosis, microcalcifications
- pseudocyst formation
- fat emboli
- lipoid meningitis
- fat migration
- déformation de contour
- occlusion artérielle
233
How does BRAVA work
ADD ANSWER
234
What are the 2 types of fat emboli et leurs principales différences
**Micro-arterial fat emboli (MIFE)**
- Mécanisme: irritation of pneumocytes par les acides gras
- onset 24-72h post-op
- affecte: peau, poumon, SNC
- Scan:Ground-glass opacity, effusion pleurale
- Mortalité:10-30%
**Macro arterial fat emboli (MAFE)**
- Mécanisme: effet d'obstruction directe sur les vaisseaux
- onset immédiat
- affecte: cardiaque failure, bradycarde
- mortalité 99%
235
List 5 risk factors in patients undergoing BBL for fat emboli
- hematological disorder
- anticoagulants
- Family history of DVT
- varicose veins
- sciatic nerve compression
236
Describe the gluteal danger triangle
- PSIS
- Ischion
- Greater trochanter
237
overall complication la plus fréquente des patients MWL qui ont une chx de contouring
déhiscence de plaie
