Liposuction Abdominoplasty Flashcards
A 42-year-old woman who has excess skin and subcutaneous tissue of the lower buttocks is scheduled to undergo excisional lipectomy with the incisions parallel to the gluteal fold. Which of the following is the most likely adverse effect? (A) Dimpling of the buttocks (B) Fat necrosis (C) Flattening of the gluteal fold (D) Painful scarring (E) Widening of the gluteal cleft
(C) Flattening of the gluteal fold
Adverse effects reported with transverse excision lipectomy include flattening and asymmetry of the buttocks and hypertrophic scarring. Dimpling of the buttocks is more commonly associated with suction lipectomy in the region overlying the glutealmuscles because of the large amount of fibrous septa between the fascia and skin. Widening of the gluteal cleft is uncommon because the incision is made parallel to the gluteal fold.
Fat necrosis does not generally occur in the buttocks because of the good vascularity in this region. Long-term painful scarring is also rare.
Fat necrosis after excision lipectomy of the buttocks
Fat necrosis does not generally occur in the buttocks because of the good vascularity in this region.
Adverse effects reported with transverse excision lipectomy of the lower buttocks
Adverse effects reported with transverse excision lipectomy of the lower buttocks include flattening and asymmetry of the buttocks and hypertrophic scarring.
What procedure is dimpling of the buttocks associated with and why?
Dimpling of the buttocks is more commonly associated with suction lipectomy in the region overlying the glutealmuscles because of the large amount of fibrous septa between the fascia and skin.
A 40-year-old woman says she has a burning pain in the thigh with movement the day after undergoing abdominoplasty. Which of the following nerves was most likely injured during the procedure? A) Genitofemoral B) Iliohypogastric C) Ilioinguinal D) Lateral femoral cutaneous E) Saphenous
D) Lateral femoral cutaneous
In several studies of complications of abdominoplasty, the most common nerve injury was to the lateral femoral cutaneous nerve. Symptoms include anterior and lateral thigh burning, tingling, and/or numbness, all of which increase with standing, walking, or hip extension. Injury or entrapment of the lateral femoral cutaneous nerve is also known as meralgia paresthetica.
Meralgia paresthetica
Injury or entrapment of the lateral femoral cutaneous nerve is also known as meralgia paresthetica.
The most common nerve injury from abdominoplasty
Lateral femoral cutaneous nerve
Symptoms of injury to the lateral femoral cutaneous nerve
Symptoms include anterior and lateral thigh burning, tingling, and/or numbness, all of which increase with standing, walking, or hip extension.
The genitofemoral nerve supplies:
The genitofemoral nervesupplies the proximal portion of the thigh about the femoral triangle just lateral to the skin that is innervated by the ilioinguinal nerve.
The iliohypogastic nerve arises from:
The iliohypogastric nerve arises primarily from L1.
Distribution of the cutaneous sensation of the iliohypogastric nerve
The distribution of the cutaneous sensation of the iliohypogastric nerve is most commonly a small region just superior to the pubis.
Injury to the iliohypogastric nerve
The iliohypogastric nerve is rarely injured in isolation. Symptoms include burning pain into the inguinal and suprapubic region.
The ilioinguinal nerve arises from:
The ilioinguinal nerve arises from the fusion of the T12 and L1 nerve roots and pierces the transversus abdominis and internal oblique muscles.
The ilioinguinal nerve supplies:
The nerve then supplies sensory branches to the pubic symphysis, the superior and medial aspect of the femoral triangle, and either the root of the penis and anterior scrotum in men or the mons pubis and labia majora in women.
Injury to the ilioinguinal nerve
The nerve can be injured in abdominoplasty and other lower abdominal incisions. Symptoms include paresthesia of the skin along the inguinal ligament. The sensation may radiate to the lower abdomen. Pain may be localized to the medial groin, the labia majora or scrotum, and the inner thigh.
Saphenous nerve symptoms of entrapment
Saphenous nerve symptoms of entrapment may include a deep aching sensation in the thigh, knee pain, and paresthesias in the cutaneous distribution of the nerve in the leg and foot
A 27-year-old woman comes to the office for consultation regarding mesotherapy for minimal lipodystrophy of the flank regions. She asks about the relative effectiveness of nonsurgical treatment with mesotherapy as compared to suction lipectomy. Which of the following is the most appropriate response?
A)Mesotherapy is as effective as suction lipectomy, and it is approved by the US Food and Drug Administration (FDA)
B) Mesotherapy is as effective as suction lipectomy, but it is not FDA-approved
C) Mesotherapy is not as effective as suction lipectomy, and it is FDA-approved
D) Mesotherapy is not as effective as suction lipectomy, and it is not FDA-approved
D) Mesotherapy is not as effective as suction lipectomy, and it is not FDA-approved
Currently, mesotherapy is not an effective alternative to suction lipectomy and is not approved by the US Food and Drug Administration (FDA).
Mesotherapy
Mesotherapy involves the subcutaneous injection of medications as a nonsurgical alternative to suction lipectomy.
Although used initially in the treatment of psoriasis, chronic pain, and cellulite, mesotherapy has been advocated as an alternative to suction lipectomy.
Mesoderm
Layer of fat and connective tissue below the skin
Most common medications used for lipolysis in mesotherapy
In mesotherapy, a variety of medications are injected into the mesoderm, the layer of fat and connective tissue below the skin. The most common medications utilized for lipolysis are phosphatidylcholine and isoproterenol.
A 53-year-old woman who underwent laparoscopic gastric bypass surgery comes to the office for consultation regarding abdominal contouring. History includes an open cholecystectomy, ventral hernia repair, appendectomy, and caesarean delivery. The presence of which of the following scars on this patient's abdomen is most likely to result in postoperative wound healing complications? A) Laparoscopic port scar B) Pfannenstiel (low transverse) scar C) Right lower quadrant scar D) Right subcostal scar E) Upper midline scar
D) Right subcostal scar
The blood supply to the abdominal wall arises from the intercostal arteries, the superior and inferior superficial epigastric arteries, and the perforators from the deep superior epigastric arteries through the rectus abdominis muscle. In a traditional abdominoplasty with undermining of the superior flap up to the costal margin, the superficial inferior epigastric arteries and the perforators that arise from the rectus abdominis muscles are divided. This leaves the abdominal flap to survive on the flow from the intercostal vasculature. The subcostal scar from the prior open cholecystectomy is the most likely scar to pose a problem for wound healing in the patient described. This scar has divided the blood flow through the intercostal circulation; thus, flow inferior to the scar may be unreliable.
The blood supply to the abdominal wall
The blood supply to the abdominal wall arises from the intercostal arteries, the superior and inferior superficial epigastric arteries, and the perforators from the deep superior epigastric arteries through the rectus abdominis muscle.
In a traditional abdominoplasty with undermining of the superior flap up to the costal margin, the ____________ arteries and the ____________ that arise from the rectus abdominis muscles are divided. This leaves the abdominal flap to survive on the flow from the ____________
In a traditional abdominoplasty with undermining of the superior flap up to the costal margin, the superficial inferior epigastric arteries and the perforators that arise from the rectus abdominis muscles are divided. This leaves the abdominal flap to survive on the flow from the intercostal vasculature.
Pfannenstiel incision
Low transverse c-section scar
A 38-year-old woman undergoes suction-assisted lipectomy of the hips, abdomen, and outer thighs. Using a super-wet technique, 3 L of aspirate is obtained. Which of the following is the most accurate estimate of the percentage of fluid infiltrate that remains in the body at the end of the procedure? A) 10% B) 30% C) 50% D) 70% E) 90%
D) 70%
The most accurate estimate of infiltrate remaining in the body is 70%. Fluid management is critical in the treatment of suction lipectomy patients. Profound hemodynamic changes occur with increasing significance as the volume of infiltrate and aspirate increases. To avoid fluid overload leading to pulmonary edema, the plastic surgeon must realize that the majority of infiltrate will remain in the patient’s body and be absorbed over time. Fluid requirements should include maintenance fluid (the amount of fluid required to replace normal daily requirements plus deficits related to being nothing-by-mouth), aspirate removed, and fluid infiltrated (70% estimated to be intravascular). These calculations will be vastly different depending on the type of wetting solution used.
Most accurate estimate of infiltrate that remains in the body after suction lipectomy
70% estimated to be intravascular
Dry technique: how much wetting solution
none
Wet technique: how much wetting solution
200-300 mL per site
Super wet technique: how much wetting solution
1 mL infiltrate for 1 mL aspirate
Tumescent technique: how much wetting solution
3 mL infiltrate for 1 mL aspirate
A 42-year-old man comes to the office because of numbness and pain near the elbow 1 year after undergoing bilateral L-brachioplasty following a 150-lb (68-kg) weight loss. Current weight is 200 lb (90 kg) and BMI is 32 kg/m2. Nerve electrical conduction studies are most likely to demonstrate injury to which of the following sensory nerves? A) Lateral antebrachial cutaneous B) Medial antebrachial cutaneous C) Posterior antebrachial cutaneous D) Radial dorsal cutaneous E) Ulnar dorsal cutaneous
B) Medial antebrachial cutaneous
Reported complication rate from brachioplasty
25-40%
Most common complications of brachioplasty are considered minor and include seroma, poor scarring, edema, wound dehiscence, and underresection.
Most common major complication of brachioplasty and rate
The most common major (NOT minor, which is unattractive scarring) complication is cutaneous nerve injury, which can occur in up to 5% of patients
Where is the preferred location for brachioplasty incision?
Medial placement of the brachioplasty incision in the bicipital groove is preferred because the ultimate scar will be hidden when the arm is adducted. Medial placement of the incision may damage the cutaneous nerves that run in this area
Origin of the medial antebrachial cutaneous nerve
Medial cord of the brachial plexus
Origin of the medial brachial cutaneous nerve
Medial cord of the brachial plexus
Anatomy of the medial brachial cutaneous nerve
The medial brachial cutaneous nerve runs with the basilic vein and sends two to four branches to the skin 7 cm proximal to the medial epicondyle. Another three to five branches pierce the fascia to innervate the skin at about 15 cm proximal to the medial epicondyle.
Anatomy of the medial antebrachial cutaneous nerve
The medial antebrachial cutaneous nerve runs in close proximity with the intramuscular septum and penetrates the fascia approximately 14 cm proximal to the medial epicondyle. At this point, the nerve runs superficially and is at risk for injury during brachioplasty.
Why are injuries to the median and ulnar nerve less common with brachioplasty?
While injuries to motor branches of the median and ulnar nerve have been reported, these branches run deep to the brachial fascia and are not injured unless the intramuscular septum is inadvertently punctured.
A 45-year-old woman comes to the office for consultation regarding body contouring 2 years after undergoing gastric bypass surgery. She has lost 120 lb (54 kg) since the procedure was performed. Height is 5 ft 5 in (165 cm), and weight has been stable at 160 lb (72 kg) for 11 months. The patient desires to undergo as few stages as possible. Lower body lift and bilateral mastopexy are scheduled to be performed in a single stage. Which of the following postoperative complications is most likely to occur in this patient? A)Dehiscence B)Hematoma C)Infection D)Pulmonary embolism E) Seroma
A)Dehiscence
In appropriately selected patients, multiple body contouring procedures can be combined into a single stage if the surgery can be done in a timely fashion. Overall minor complication rates arehigher; however, per procedure complication rates do not seem to increase if more procedures are performed in a single stage. The most common complication in patients undergoing combined procedures in a single stage is related to wound healing issues (approximately 15%). Seroma is the next most common complication (approximately 10%). Infection, hematoma, and pulmonary embolism occur at rates of less than 5%.
Most common complications of multiple body contouring procedures when combined into single operation
Most common = Wound healing issues (approximately 15%)
Seroma is the next most common complication (approximately 10%)
Infection, hematoma, and pulmonary embolism occur at rates of less than 5%
Complications of multiple body contouring procedures into a single stage vs separate procedures
In appropriately selected patients, multiple body contouring procedures can be combined into a single stage if the surgery can be done in a timely fashion. Overall minor complication rates arehigher; however, per procedure complication rates do not seem to increase if more procedures are performed in a single stage.
A 35-year-old woman comes to the office for consultation because she is unhappy with the unevenness of her skin 1 year after undergoing power-assisted suction lipectomy using the super-wet technique. Physical examination shows skin surface irregularities that are radially oriented around a single 1-cm-wide scar. Which of the following modalities was most likely used for this outcome? A )Improper power source B) Multiple access sites C) Poor postoperative compression D) Superficial plane of suction E) Use of fine cannulas
D) Superficial plane of suction
One of the most common deformities of suction lipectomy is surface irregularity, which can have several causes. A large cannula will create a large furrow that may be visualized if the suction lipectomy is not performed evenly. Use of a single port may also lead to irregularities because the suctioning is done from only one angle. Superficial suctioning isalso more prone to visible irregularities. The best way to avoid these deformities is to use small cannulas in the deep fat, with cross-tunneling from two sites, such that the tunnels are at right angles to each other. The power source would not cause surface irregularities. Lack of compression will cause prolonged edema, but not surface irregularities.
Suction lipectomy: risk factors for contour irregularity
A large cannula will create a large furrow that may be visualized if the suction lipectomy is not performed evenly. Use of a single port may also lead to irregularities because the suctioning is done from only one angle. Superficial suctioning isalso more prone to visible irregularities.
Suction lipectomy: reducing risk of contour irregularity
The best way to avoid these deformities is to use small cannulas in the deep fat, with cross-tunneling from two sites, such that the tunnels are at right angles to each other.
A 48-year-old woman is scheduled to undergo abdominoplasty. She has smoked one pack of cigarettes daily for the past 10 years. During the preoperative visit, she informs the plastic surgeon that she has been on a nicotine patch and has not been smoking for 3 weeks. Which of the following mechanisms is most likely to cause wound healing complications in this patient?
A ) Decreased availability of hemoglobin
B ) Decreased red blood cell deformability
C ) Impairment of leukocyte function
D ) Increased fibrinogen production
E ) Increased microvascular vasoconstriction
E ) Increased microvascular vasoconstriction
The nicotine in cigarettes causes vasoconstriction of cutaneous blood vessels with resultant decreased tissue oxygenation. Smoking also increases carboxyhemoglobin, increases platelet aggregation, increases blood viscosity, decreases collagen deposition, and decreases prostacyclin formation, which all negatively affect wound healing. In addition, vasoconstriction associated with smoking is not a transient phenomenon. Smoking a single cigarette may cause cutaneous vasoconstriction for up to 90 minutes; hence, a patient who smokes one pack of cigarettes daily remains tissue hypoxic for most of each day.
Smoking a single cigarette may cause cutaneous vasoconstriction for up to ___ minutes
Smoking a single cigarette may cause cutaneous vasoconstriction for up to 90 minutes
Smoking vs wound healing (other than just vasoconstriction)
Smoking also increases carboxyhemoglobin, increases platelet aggregation, increases blood viscosity, decreases collagen deposition, and decreases prostacyclin formation, which all negatively affect wound healing.
Immune system vs nicotine
The proliferation of macrophages and fibroblasts, which are integral to the phases of wound healing, is also diminished by the presence of nicotine.
A 23-year-old woman comes to the office for consultation regarding significant skin laxity and volume loss in the face, torso, and upper and lower extremities following gastric bypass surgery 22 months ago. She has lost 120 lb (54 kg) since the procedure was performed. Rhytidectomy, abdominoplasty, brachioplasty, back lift, and thigh lift will be performed in three stages. Which of the following procedures will most likely result in hypertrophic scarring? A ) Abdominoplasty B ) Back lift C ) Brachioplasty D ) Mastopexy E ) Rhytidectomy
C ) Brachioplasty
Hypertrophic scarring is reported to occur in up to 40% of brachioplasty cases. These scars require compression therapy, silicone sheeting, or mild corticosteroid injections. The other body regions are less likely to scar in a hypertrophic fashion
Hypertrophic scarring is reported to occur in up to __% of brachioplasty cases.
Hypertrophic scarring is reported to occur in up to 40% of brachioplasty cases. These scars require compression therapy, silicone sheeting, or mild corticosteroid injections. The other body regions are less likely to scar in a hypertrophic fashion
A 38-year-old woman comes to the office desiring abdominoplasty. History includes easy bruising and four spontaneous abortions in the first trimester and one live birth. Her infant weighed 10 lb 8 oz (4.5 kg) at birth. The patient's BMI is 28 kg/m2. Examination shows a 6-cm diastasis recti, an abdominal pannus, and a well-healed Pfannenstiel incision. Which of the following consultations is most appropriate for this patient before proceeding with surgery? A ) Cardiologist B ) Endocrinologist C ) General surgeon D ) Hematologist E ) Nutritionist
D ) Hematologist
Multiple spontaneous abortions are highly suggestive of a hypercoagulation diathesis and should be further evaluated.
Venous thromboembolic events (VTEs), which include both deep venous thrombosis and pulmonary emboli, remain a significant cause of morbidity and mortality in surgical patients. The most commonly associated aesthetic procedure is abdominoplasty.
Aesthetic procedure most commonly associated with DVT and PE
Abdominoplasty
Most common genetic abnormality
The most common genetic abnormality is Factor V Leiden, which is a mutated factor V resistant to inactivation by activated protein C.
How common is Factor V Leiden?
This abnormality is present in 3 to 7% of the Caucasian population.
Common thrombphilic conditions
Factor V Leiden, prothrombin variant 20210A, antiphospholipid antibodies, protein C or S deficiency, antithrombin deficiency, and hyperhomocysteinemia
A 40-year-old man becomes increasingly disoriented and obtunded 1 day after belt lipectomy. He has had a 200-lb (91-kg) weight loss since undergoing gastric bypass surgery 22 months ago. Which of the following is the most appropriate initial step in management? A ) Anesthesia consultation B ) Duplex ultrasonography of the legs C ) Heparin therapy D ) Psychiatric evaluation E ) Thiamine therapy
E ) Thiamine therapy
Many massive weight-loss patients suffer from malnutrition, including thiamine deficiency, which can lead to Wernicke-Korsakoff encephalopathy. Treatment is intravenous administration of 100 mg/d of thiamine, continuing with 100 mg every 8 hours until resolution of symptoms. Administration of thiamine is low risk and may reverse symptoms.
Disorientation in a massive weight loss patient
Many massive weight-loss patients suffer from malnutrition, including thiamine deficiency, which can lead to Wernicke-Korsakoff encephalopathy. Treatment is intravenous administration of 100 mg/d of thiamine, continuing with 100 mg every 8 hours until resolution of symptoms. Administration of thiamine is low risk and may reverse symptoms.
Treatment for Wernicke-Korsakoff encephalopathy
Treatment is intravenous administration of 100 mg/d of thiamine, continuing with 100 mg every 8 hours until resolution of symptoms.
A 57-year-old woman comes for evaluation for body contouring. She takes no medications except garlic herbal tablets daily. Use of the herbal medication increases her risk for which of the following postoperative events? A ) Bleeding B ) Hypertension C ) Nausea and vomiting D ) Prolonged anesthesia effects E ) Tachycardia
A ) Bleeding
Garlic ingestion may also increase the risk of intraoperative or postsurgical bleeding secondary to its platelet inhibitor activity or its role as a stimulator of fibrinolytic activity
When should patients stop taking garlic vs surgery?
It is generally recommended that patients discontinue garlic use 7 days prior to surgery to reduce the risk of possible bleeding complications.
A 32-year-old woman is scheduled to undergo suction lipectomy of the outer thighs and flank areas. One liter of solution composed of Ringer's lactate solution mixed with 20 mL of 2% lidocaine and one ampule of epinephrine with a concentration of 1:1000 will be used. Which of the following is the amount of lidocaine in the mixture described? A ) 100 mg B ) 200 mg C ) 300 mg D ) 400 mg E ) 500 mg
D ) 400 mg
Each liter of solution contains 400 mg of lidocaine with a concentration of 0.04% and 1:1,000,000 epinephrine.
Why is lidocaine chosen for wetting solution?
Lidocaine is used more often as the anesthetic agent in the wetting solution. It has a wider range of safety than bupivacaine (Marcaine) and is more easily reversed.
Safe dose of lidocaine in wetting solution
It is generally accepted that a dose of lidocaine up to 35 mg/kg is safewhen injected into the subcutaneous fat with solutions containing epinephrine, although doses up to 50 mg/kg have been utilized.
An otherwise healthy 38-year-old woman reports feeling faint when she stands up 1 day after undergoing contouring of the abdomen, back, and thighs. Prior to the contouring procedure, she underwent a Roux-en-Y procedure 2 years ago and lost 183 lb (83 kg). BMI is now 23 kg/m2. Pulse is 120/min, and bloodpressure is 90/60 mmHg. Which of the following is the most likely underlying cause of this patient's condition? A ) Anemia B ) Hypothermia C ) Pain D ) Skin necrosis E ) Vitamin deficiency
A ) Anemia
Many patients who have undergone Roux-en-Y gastric bypass surgery have underlying iron deficiency anemia, vitamin B12 (cobalamin) deficiency, and fat soluble vitamin deficiency.
Deficiencies in patients who have undergone Roux-en-Y gastric bypass surgery
Many patients who have undergone Roux-en-Y gastric bypass surgery have underlying iron deficiency anemia, vitamin B12 (cobalamin) deficiency, and fat soluble vitamin deficiency. These deficiencies may lead to blood clotting disorder.
A 44-year-old woman is brought to the emergency department because of the sudden onset of heart palpitations and anxiety 12 hours after undergoing abdominoplasty and liposuction. History includes breast cancer. She uses a transdermal patch for contraception. Height is 5 ft 5 in (165 cm) and weight is 152 lb (69 kg). During the abdominoplasty procedure, 4 L of Ringer’s lactate containing lidocaine 25 mg/L and epinephrine 1 mg/L were infused prior to the first incision, and 4.1 L of aspirate were obtained. Recovery had been uneventful until the current episode. Which of the following is the most appropriate management?
A ) Administration of 0.5 mg alprazolam (Xanax)
B ) CT scan of the chest
C ) Determination of serum lidocaine concentration in the blood
D ) Doppler ultrasonography of the lower extremities
E ) Reassurance and observation
B ) CT scan of the chest
The patient described most likely has an acute pulmonary embolism (PE) and should receive urgent medical attention at the nearest emergency department. Her age, recent diagnosis of breast cancer, and estrogen-based contraceptive use places her at moderate-to-high risk for deep venous thrombosis (DVT) and/or PE following surgery. In addition, the combination of large-volume liposuction and full abdominoplasty as a single procedure further increases her risk for these complications. Heart palpitations and anxiety are common complaints in patients experiencing a PE, as are shortness of breath and hyperventilation, but the diagnosis should not be overlooked in a situation like this, even if it is not a presenting symptom. A CT scan of her chest as dictated in a PE protocol is the appropriate diagnostic study to evaluate for PE and will provide the necessary justification to initiate anticoagulation therapy.
A plastic surgeon is approached by a guest while attending a fund-raising event. The woman asks whether she should have an abdominoplasty procedure, and they discuss specific details regarding it. The woman subsequently calls the office and makes an appointment. On arrival, she gives a detailed history to the office nurse and is examined by the plastic surgeon. The procedure is scheduled and performed 3 weeks later. At which of the following stages of this scenario was a doctor-patient relationship established?
A ) When the discussion at the fundraiser took place
B ) When the patient made an appointment
C ) When the nurse took a detailed history
D ) When the physician examined the patient
E ) When the procedure was performed
A ) When the discussion at the fundraiser took place
Duty is created when the doctor-patient relationship is established. Simply being a physician does not obligate one to establish that relationship. The doctor-patient relationship is formed when a doctor has professional contact with a patient, but it is not necessary to see the patient physically to form this relationship. Anyone the physician supervises and has authority over, even an office clerk, can form the doctor-patient relationship with the physician. If the plastic surgeon gives specific advice, it establishes a doctor-patient relationship. A physician should never enter into a doctor-patient relationship by accident.
When can malpractice happen?
Malpractice is negligence that occurs in the performance of a profession. The four elements of negligence are:
- Duty owed -the existence of an obligation
- Duty breached -failure to deliver the obligation
- Causation -the link between breach and harm
- Damages -patient injury
A 35-year-old man is scheduled to undergo a medial thigh lift. He underwent bariatric surgery 2 years ago and has lost 120 lb (54 kg). To decrease the risk of seroma formation, care must be taken to preserve the area defined by the inguinal ligament and which of the following additional structures?
A ) Adductor longus muscle and sartorius muscle
B ) Gracilis muscle and adductor magnus muscle
C ) Great saphenous vein and sartorius muscle
D ) Iliopsoas muscle and adductor magnus muscle
A ) Adductor longus muscle and sartorius muscle
The incidence of seroma following medial thigh lift ranges from 4 to 20%, making it one of the most common complications of body contouring. It is critical to have an appreciation of the anatomical borders of the femoral triangle for two reasons. First, the concentration of lymphatics draining the lower extremity is very high within the femoral triangle. Second, direct injury to the inguinal lymphatic system often occurs inconspicuously, and so a preemptive approach should be taken to protect these structures.The femoral triangle is bordered by the inguinal ligament, adductor longus muscle, and sartorius muscle. The iliopsoas muscle, pectineus muscle, inguinal lymph nodes, and femoral nerve, artery, and vein reside within the femoral triangle, as does the proximal portion of the great saphenous vein.
Borders of the femoral triangle
The femoral triangle is bordered by the inguinal ligament, adductor longus muscle, and sartorius muscle. The iliopsoas muscle, pectineus muscle, inguinal lymph nodes, and femoral nerve, artery, and vein reside within the femoral triangle, as does the proximal portion of the great saphenous vein.
Medial thigh lift: Incidence of serum formation
4-20%
Medial thigh lift: why is it important to appreciate the anatomical borders of the femoral triangle?
It is critical to have an appreciation of the anatomical borders of the femoral triangle for two reasons.
- First, the concentration of lymphatics draining the lower extremity is very high within the femoral triangle.
- Second, direct injury to the inguinal lymphatic system often occurs inconspicuously, and so a preemptive approach should be taken to protect these structures
A 62-year-old man is scheduled to undergo repair of an abdominal wall hernia. A preoperative photograph isshown. He has a 15-year history of chronic lung disease and receives daily corticosteroids to control his symptoms. Supplementation with which of the following is most likely to decrease impairment of wound healing in this patient? A) Vitamin A B) Vitamin B1 (thiamine) C) Vitamin B2 (riboflavin) D) Vitamin B6 (pyridoxine) E) Vitamin C
A) Vitamin A
Animal studies have shown that impairment of wound healing caused by use of corticosteroids can be reversed by the oral administration of vitamin A (retinoic acid), 15,000 IU daily for seven days.
Impairment of wound healing can be reversed by:
Vitamin A
A 49-year-old woman who underwent gastric bypass surgery. She has lost 100 lb, going from a body mass index (BMI) of 45 kg/m2to 28 kg/m2, and now has excess anterior abdominal and buttock tissue.
Most appropriate procedure:
Circumferential lower body lift
A 55-year-old man with a BMI of 40 kg/m2, who has had episodes of severe intertrigo and skin infections from overhanging skin and fat of the anterior abdomen. He has smoked one half of a pack of cigarettes daily for five years.
Most appropriate procedure:
Panniculectomy
A 42-year-old man develops a dehiscence of the abdominal incision six weeks after undergoing a lower body lift. Medical history includes a 100-lb (45-kg) weight loss during the past three years. Which of the following is the most likely cause of the wound-healing problem? A ) Hematoma B ) Patient movement C ) Seroma D ) Skin necrosis E ) Wound infection
C ) Seroma
Body lift procedures after massive weight loss have a complication rate of approximately ___%.
Body lift procedures after massive weight loss have a complication rate of approximately 50%.
Early vs late wound dehiscence in body lift procedures
Early wound dehiscence may be caused by patient movement, while late wound dehiscence is often due to underlying seroma.
The most common complication is ______________, which occurs in greater than ___% of patients.
The most common complication is wound dehiscence, which occurs in greater than 30% of patients.
Which of the following is most indicative of the aging male abdomen as compared with the aging female abdomen?
A ) Accumulation of fat peripherally below the iliac crest
B ) Greater skin laxity
C ) Less intra-abdominal accumulation of fat
D ) Thinner skin with tendency toward striation
E ) Wider upper rectus muscle diastasis
E ) Wider upper rectus muscle diastasis
Men are more likely to have a wide upper rectus muscle diastasis, and women are more likely to have a lower rectus muscle diastasis. Men’s skin tends to be thicker and less prone to laxity and striation. The accumulation of flank fat is more central in men and located moreperipherally below the iliac crest in women. Men have more intra-abdominal accumulation of fat, although women can accumulate intra-abdominal fat more commonly after menopause.
Rectus diastasis: Women vs men
Men are more likely to have a wide upper rectus muscle diastasis, and women are more likely to have a lower rectus muscle diastasis.
Flank fat: Women vs men
The accumulation of flank fat is more central in men and located more peripherally below the iliac crest in women.
Intra-abdominal accumulation of fat: Men vs women
Men have more intra-abdominal accumulation of fat, although women can accumulate intra-abdominal fat more commonly after menopause.
A 34-year-old woman is scheduled to undergo brachioplasty following a 100-lb (45-kg) weight loss. Which of the following is the most likely unfavorable outcome of the procedure in this patient? A ) Contour deformities B ) Lymphedema C ) Neuroma D ) Seroma E ) Unattractive scarring
E ) Unattractive scarring
The most common complication of brachioplasty in postbariatric body contouring is hypertrophic, widened, or unattractive scarring. This multifactorial problem is secondary to problems in geometry (tension and compression), multiple vectors, tissue mismatch, nutrition, and adequate resection.
A 35-year-old woman is scheduled to undergo liposuction in an office-based setting. Height is 5 ft 10 in (178 cm) and weight is 185 lb (84 kg). According to the American Society of Plastic Surgeons Committee on PatientSafety, the recommended maximum total volume of aspirate should be limited to which of the following amounts? A ) 4000 mL B ) 5000 mL C ) 6000 mL D ) 7000 mL E ) 8000 mL
B ) 5000 mL
In the “Practice Advisory on Liposuction” the American Society of Plastic Surgeons Committee on Patient Safety defines large-volume liposuction as more than 5 L of lipoaspirate taken in one operation.
A 30-year-old woman has numbness of the forearm following a brachioplasty procedure to correct significant skin laxity. Which of the following nerves was most likely injured during the procedure? A ) Axillary B ) Intercostal brachial C ) Medial antebrachial cutaneous D ) Posterior interosseous E ) Ulnar
C ) Medial antebrachial cutaneous
The medial antebrachial cutaneous (MABC) nerve may be located within the resection area of the arm during brachioplasty, leading to regional paresthesia in the upper arm and the anterior proximal forearm.
A 57-year-old woman is scheduled to undergo a medial thigh lift. Anchoring of the soft tissue of the medial thigh to the Colles fascia is planned. The Colles fascia is continuous with which of the following structures?
A ) Anococcygeal raphe
B ) Anterior rectus sheath
C ) Deep layer of the deep perineal fascia
D ) Posterior urogenital diaphragm
E ) Scarpa’s fascia of the abdominal wall
E ) Scarpa’s fascia of the abdominal wall
It is described as the deep layer of the superficial perineal fascia (not the deep perineal fascia) and lies deep to the subcutaneous fat of the perineum. Anteriorly, it is continuous with Scarpa’s fascia of the abdominal wall. It is distinct, unrelated, and not continuous with the anterior rectus sheath. Posteriorly, Colles fascia fuses with the posterior border of the urogenital diaphragm. It does not occur posterior to this structure. The Colles fascia is high in elastin content, giving it a yellow hue which distinguishes it from nearby white muscular fascia.
Colles fascia content/color
The Colles fascia is high in elastin content, giving it a yellow hue which distinguishes it from nearby white muscular fascia
Colles fascia
It is described as the deep layer of the superficial perineal fascia (not the deep perineal fascia) and lies deep to the subcutaneous fat of the perineum. Anteriorly, it is continuous with Scarpa’s fascia of the abdominal wall. Posteriorly, Colles fascia fuses with the posterior border of the urogenital diaphragm. It does not occur posterior to this structure.
A 56-year-old woman comes to the office for consultation regarding aesthetic improvement ofher abdomen. She says she is unhappy about the excess abdominal fat and skin, an unattractive abdominal contour from a previous surgery, and the size and ptosis of the mons area. A fleur-de-lis abdominoplasty is planned. To achieve optimal aesthetic improvement of the mons area, the lower incision should be made at which of the following locations? (A)2.5 cm above the vulvar commissure (B)5 cm above the vulvar commissure (C)Panniculus crease (D)Pubic hairline (E)Vulvar commissure
(B)5 cm above the vulvar commissure
To maximize the lift in the mons area without incurring an abnormal contour, the incision should be placed 5 to 7 cm above the vulvar commissure and within the hairline.
Maximizing the mons area in abdominoplasty: incision placement
To maximize the lift in the mons area without incurring an abnormal contour, the incision should be placed 5 to 7 cm above the vulvar commissure and within the hairline.
A 30-year-old woman comes to the office for consultation regarding a body lift two years after undergoing a gastric bypass procedure. On initial evaluation, the presence of which of the following medications would increase the patient’s risk for an embolic event during surgery? (A)Anticholesterol medications (B)Antidepressants (C)Diuretics (D)Oral contraceptives (E)Thyroid replacement
(D)Oral contraceptives
Patients undergoing bariatric procedures have many of the known risk factors for embolic events, such as long procedure duration, immobilization, and obesity. The risk of deep venous thrombosis, even with prophylaxis, has been reported to be as great as 9%. Oral contraceptives and estrogen replacement therapy are known to increase the rate of embolic problems, and patients should be counseled to stop these medications, if possible, before the procedure.
A 36-year-old woman is scheduled to undergo a circumferential body lift procedure for correction of skin laxity resulting from a 100-lb weight loss. After the preoperative consultation, a simultaneous procedure to correct the flat and unnatural appearance of the patient’s buttocks is planned. Which of the following is the most appropriate method of buttock augmentation for this patient? (A)Autologous gluteal flaps (B)Autologous fat injections (C)Silicone gel prostheses (D)Solid silicone prostheses
(A)Autologous gluteal flaps
Autologous gluteal flaps provide easily accessible donor tissue that can be used simultaneously in body lift procedures. The dermal fat flaps can be elevated safely to autoaugment the buttocks. This technique adds no more than 45 minutes to the procedure and does not addto the usual complications of body lift procedures in general
Autologous fat transfer for buttock shape
Autologous fat transfer can be used to enhance buttock shape, but unfortunately the buttocks of many of these patients are deflated and do not have adequate donor sites for grafting.
Silicone prostheses for buttock augmentation
Silicone prostheses, both solid and gel types, are associated with less than optimal outcomes because of palpability and a greater risk of infection and dehiscence.
A 45-year-old woman is undergoing abdominoplasty. She does not smoke cigarettes and currently takes estrogen replacement medication. Medical history includes a deep venous thrombosis with no pulmonary embolus 12 years ago. Which of the following is the most appropriate thromboembolism prophylaxis in this patient?
(A)Administration of aspirin
(B)Administration of enoxaparin and application of sequential compression devices
(C)Administration of warfarin pre-and postoperatively
(D)Application of elastic stockings and intravenous administration of heparin
(E)Early ambulation
(B)Administration of enoxaparin and application of sequential compression devices
A 54-year-old woman who recently had a 40-lb weight loss is scheduled to undergo a medial thigh lift procedure. Which of the following closure techniques for this procedure is most effective in decreasing the risk of lymphedema of the legs and knees?
(A)Anchoring the inferior skin flap to the superficial layer of the superficial fascia of the perineum
(B)Closing the flap to the recipient areas using the Scarpa fascia
(C)Superficial dissection over the femoral triangle
(D)Suturing the superficial fascial system of the flap to the Colles fascia
(E)Undermining the inferior skin flap deep to the adductor muscle fascia
(C)Superficial dissection over the femoral triangle
The superficial fascia of the medial thigh consists of ___ layers: ___________
The superficial fascia of the medial thigh consists of two layers: superficial and deep.
Using the ________ as the central anchor for the medial thigh lift has produced more consistent and long-lasting results, decreasing the risk of problems commonly associated with the classic skin-suspension medial thigh lift:
Using the Colles fascia as the central anchor for the medial thigh lift has produced more consistent and long-lasting results, decreasing the risk of problems commonly associated with the classic skin-suspension medial thigh lift—widened scars and labial distortion.
A 45-year-old woman who has had a 100-lb weight loss since undergoing gastric banding two years ago comes to the office for consultation regarding loose skin on her upper arms. Physical examination shows significant ptosis of the posteromedial aspect of the upper arms and relaxation of the soft tissue. Fascia in which of the following regions is also relaxed in this patient and is appropriate for use as an anchor during brachioplasty to reduce widening and hypertrophy of the scars? (A)Axillary (B)Bicipital (C)Deltoid (D)Pectoral (E)Tricipital
(A)Axillary
An important etiologic mechanism of the aesthetic arm deformity is relaxation of a longitudinal fascial system sling that extends from the clavicle to the soft tissues of the posteromedial aspect of the arm via the clavipectoral and axillary fascia. Reanchoring the soft tissues of the posteromedial aspect of the arm to the axillary fascia with nonabsorbable sutures addresses the relaxation of the axillary fascia sling and forms the basis for the anchor brachioplasty. Similarly to anchoring the soft tissues of the medial aspect of the thigh to the Colles fascia (perineum) in medial thigh lifts, fascial anchoring in brachioplasties provides more predictable results while reducing complications.
Similarly to anchoring the soft tissues of the medial aspect of the thigh to the Colles fascia (perineum) in medial thigh lifts, ________ anchoring in brachioplasties provides more predictable results while reducing complications.
Similarly to anchoring the soft tissues of the medial aspect of the thigh to the Colles fascia (perineum) in medial thigh lifts, fascial anchoring in brachioplasties provides more predictable results while reducing complications.
Reanchoring the soft tissues of the posteromedial aspect of the arm to the ________ addresses the relaxation of the ____________ and forms the basis for the anchor brachioplasty.
Reanchoring the soft tissues of the posteromedial aspect of the arm to the axillary fascia with nonabsorbable sutures addresses the relaxation of the axillary fascia sling and forms the basis for the anchor brachioplasty.
A 40-year-old woman comes to the office for follow-up examination three weeks after undergoing traditional brachioplasty for correction of skin laxity in the proximal aspect of the upper arms. She has had persistent numbness along the medial aspect of the elbow and forearm, extending to the level of the wrist. Which of the following nerves was most likely injured during brachioplasty in this patient? (A)Intercostobrachial (B)Medial antebrachial cutaneous (C)Medial brachial cutaneous (D)Musculocutaneous (E)Posterior brachial cutaneous
(B)Medial antebrachial cutaneous
The medial antebrachial cutaneous nerve branches, together with the basilic vein, exit the deep fascia of the medial arm at the transition between the middle and distal thirds of the arm. Care should be taken at the time of surgery to identify this nerve at this level and maintain more fat on the deep fascia to prevent injury.