KEY NOTES CHAPTER 9: AESTHETIC SURGERY - Body Contouring. Flashcards
What surgical methods of weight loss are there?
Restrictive.
Restrictive with malabsorption.
Who described the superficial fascial system?
Lockwood - described the anatomy.
SFS:
- connective tissue network from subnormal plane to muscle fascia.
- consists of horizontal membranous sheets separated by adipose tissue and interconnecting vertical or oblique septa.
- function: support fat, anchors skin to deep tissues.
- becomes lax with age.
- suspending SFS in body contouring procedures diffuses tension on skin flaps (like SMAS in facelift).
Zones of adherence:
- defines body contour
- at skin creases: inframammary, groin, gluteal, periarticular/
- anterior and posterior sagittal midlines of trunk
- inguinal region to lateral gluteal fold
What types of restrictive procedures are there?
- vertical banded gastroplasty.
- adjustable gastric band - circumferential silicone balloon around upper stomach with subcutaneous port for inflation and deflation.
Aim: creates a small proximal stomach pouch.
Should be deflated pre-abdominoplasty to decrease aspiration risk.
What types of restrictive with malabsorption procedures are there?
- Biliopancreatic diversion - diverts biliopancreatic contents to distal ileum.
- Duodenal switch - similar to BPD but preserves pylorus to improve gastric emptying.
- Roux-en-Y - small gastric pouch created from cardia which drains into distal small bowel. Remaining proximal small bowel is anastomosed to distal small bowel (?)
Dietary supplementation is required: thiamine, folate, cobalamin (Vit B1, 9, 12), iron and calcium.
How do you assess a MWL patient? History.
Congratulate patient! Acknowledge it is life-changing event. Mechanism of WL. Highest weight and BMI. Lowest weight since MWL. Current weight & BMI. How long weight has been stable. Target weight.
Pregnancies (none, natural or Caesarean).
Prior surgery - intra-abdo, gastric bypass, last appmt with Bariatric team.
Hx of DVT, PE, hyper-coagulable state.
Smoking, Diabetes.
Nutritional status Diet Protein intake (goal 70g/d) Vitamins (calcium, B12, iron) Nausea, vomiting Dumping syndrome
Exercise regime
Attendance to support groups, support network (family and friends)
Consultations with following and optimize preop: Cardiology, respiratory, medical, nutrition, psychiatry.
Establish pt’s goals, main areas of concern
Are they realistic?
Trading excess skin and fat for new contours and scars
How do you assess a MWL patient? Examination.
BMI, height and build.
(Pittsburgh Weight Loss Deformity Scale helps grade problems in specific body areas.)
Quality of skin, distribution of skin laxity:
- Remaining adiposity, asymmetry
- Rolls
- Folds
- Skin tone
- Skin integrity
- Scars
- lymphoedema, intertrigo, ulceration, varicose veins.
Abdo wall structure (rectus diastasis, hernias, thickness).
Overall constitution (?poor mobility, chronic pain, stigmata of malnutrition).
Document asymmetries.
Standardised photographs.
Develop surgical plan - if hernia, joint op with bariatric team
If hernia op / changing positions intra-op - bowel prep pt.
What would be valid reasons to defer surgery?
Emphasize to patients:
- Optimizing results
- Limiting complications
- Maximizing safety
1yr after bariatric surgery
Stable weight 3mths
BMI <35 (current literature BMI >35 has greater complications)
Exceptions: giant disabling pannus, chronic panniculitis - functional panniculectomy indicated
Appropriate nutritional status
Medially optimized
Psychologically optimized
Financially issues (multiple ops, down time)
What are the contraindications to surgery?
Absolute - Medically unfit
Relative
- Tobacco use (stop 1mth preop)
- Active intertrigo
- BMI >35
- Coagulopathies
- Collagen diseases & other disorders affecting wound healing
How are patients counselled pre-operatively?
Limitations of surgery
- striae: may look worse / stretched out.
- inelastic skin (like chewing gum) and recurrent ptosis.
- areas addressed per operation is limited by: total op time, blood loss, areas with opposing vectors of pull.
Nature of surgery
- major surgery, GA
- scars, surgical drains
Post-operative
- hospital stay
- home with compression garments, TEDS.
- swelling ~6mths, 6 months to fully recover.
What are the complications of surgery?
15%, 50% for MWL patients.
Wound healing delay, dehiscence. Skin, soft tissue necrosis. Seroma, haematoma, lymphoecele, lymphoedema. Infection. Bleeding. Asymmetry, contour irregularity. Nerve injury, neuroma. VTE. Hypertrophic keloid scarring. Recurrence.
Tell me how you do an abdominoplasty.
Mark patient in standing position: Midline, ASIS, lower incision at natural suprapubic crease, 5-7cm above vulval cleft, covered by normal underwear.
Procedure:
- Long silk suture at xiphisternum and symphysis pubis, can use to measure symmetry of incision.
- lower abdominal incision, periumbilical incision.
- Undermine at sub-Scarpa’s level to costal margin (leave some fat on rectus sheath).
- Plicate rectus sheath 0 looped nylon.
- Pull flap down, re-mark midline and assess how much excess skin to excise at midline, make midline cut up to that point, draw 15cm horizontal line.
- Temp suture midline, complete superior excision line, excise, weigh left and right pannus.
- Reposition umbilicus, 3/0 vicryl to anchor umbilicus to rectus sheath, donut and midline defatting of upper abdo flap, inverted V abdo incision.
- Multilayered closure including Scarpa’s fascia unless wide discrepancy between upper and lower skin flap thickness, cheat dog ears in laterally.
What are other variations of abdominoplasty do you know?
- Mini-abdominoplasty
- no peri-umbilical incision, skin flap only raised to umbilical level. - Lipo-abdominoplasty
- liposuction and excisional abdominoplasty (important to preserve skin flap vascularity). - Fleur-de-lis
- inverted T abdominal scar, to reduce horizontal (and vertical) skin excess. Minimal lateral undermining to preserve skin flaps. - Reverse abdominoplasty
- inframammary incision, excess dermal fat flaps can be used for autologous breast augmentation,
- combined with upper back lift = circumferential excision. - High lateral tension abdominoplasty
- Lockwood 1995
- resection places maximally tension laterally, not centrally.
- flattens abdomen, lifts anterior thighs and emphasises waist.
- SFS repaired with heavy braided nylon for lasting result.
- creates high scar, not concealed. - Panniculectomy.
What are Huger’s zones?
Zone I
- xiphoid to pubis, between each line semilunaris.
- superior and deep inferior epigastric vessels.
Zone II
- ASIS to ASIS, to inguinal creases and pubis.
- superificial circumflex iliac and superficial external pudendal vessels.
Zone III
- anterolateral abdominal wall above ASIS, lateral to line semlunaris.
intercostal, subcostal and lumbar vessels (and partly SEA and DIEA).
Zone I and II are sacrificed in abdominoplasty.
Zone III vessels may be disrupted in lipoabdominplasty.
Therefore should only undermine infra umbilical region and narrow strip either side of midline above umbilicus.
How are abdominoplasty techniques adapted in MWL patients?
Panniculectomy
- No undermining
- Umbilicus often sacrificed
- Interrupted mattress sutures to skin to encourage wound eversion
If doing vertical scar also (fleur de lis)
- No undermining to costal margin
- Excise and close transverse scar first
- Then do vertical
- Inset umbo without making further (hemi) circular incision at inset (tension on vertical scar with eventually widen umbo)
If pannus is huge, hydraulic lifts, ortho pins, traction bows, suspension from ceiling bars (as large pannus on chest will cause GA ventilatory problems)
Describe an upper back lift
- can be combined with reverse abdominoplasty or mastopexy and brachioplasty.
- mark standing, centred on bra-line, tapered anteriorly or meet reverse abdominoplasty, vertical cross-hatches to guide closure,
- prone
- upper incision, undermine just above deep fascia.
- estimate skin excess, make lower incision.
- drains
- layered closure including SFS.
