Liposuction, Abdominoplasty, and Belt Lipectomy Flashcards
Liposuction should not be offered as a treatment for global obesity
or cellulite
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patients should be within 30% or their ideal
body weight
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Women typically have a gynoid pattern of fat distribution with accumulation in the lower trunk, hips, upper thighs, and
buttocks
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Men often exhibit an android fat accumulation pattern with
increased abdominal girth, thickened torso, and upper abdomen.
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Liposuction
should be avoided in Zones of adherence or used with extreme caution in these areas as the
risk of contour irregularities is high
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Body contouring operations such as liposuction and abdominoplasty have a higher incidence of venous thrombotic complications than other plastic surgery procedures
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The use of chemoprophylaxis will depend on the preoperative risk
stratification
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use of wetting solution
has greatly improved the safety of liposuction.
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Wetting solutions
can be a variable composition but usually include
saline or lactated
Ringer’s, lidocaine, epinephrine, and sometimes sodium bicarbonate.
evolution of wetting solution techniques that have helped
decrease blood loss
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SAL is the most
frequently utilized modality among plastic surgeons
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Because PAL can break up fibrous fat more readily, this modality can significantly cut down on physician fatigue
due to shorter procedure times and employing less physical labor
to use
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How you can aviod the compilaction of the UAL?
With the use of smaller cannulas and conservative ultrasound
application times,
LAL uses a small laser fiber to emulsify fat and tighten skin
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LAL has been proven to cuase skin tightness
F However, several well-designed studies have failed to
show a significant benefit over SAL
vThe aesthetic outcomes, patient satisfaction, and incidences of long-term complications appear to be more related TO technology
F to technique
Primary endpoints for SAL/PAL/UAL is the treatment time and volume
F Seconadary end piont treatment time and volume
Cryolipolysis is a noninvasive technique to destroy adipose cells through administration of
controlled thermal reduction via a specialized machine
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Because
of their susceptibility, exposure ofadipose cells to below normal temperatures (+5° to -5°C) results in apoptosis-mediated cell death with
preservation of overlying skin integrity
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The subsequent inflammatory cascade results in removal of the damaged cells over the course
of 3 months.
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complication following cryolipolysis
hypoesthesia of the treatment area that usually resolves over
several months. Other less common complications include surface
contour irregularities, chronic pain, and rarely, paradoxical adipose
hyperplasia
The deep plane is suctioned first
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Cross-hatching or cross-tunneling is the method of using the liposuction cannula via multiple access sites to create intersecting sets of
parallel lines over the treated area. This helps to ensure the tissue is
suctioned more symmetrically and evenly
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separation step in SAFE tech uses an exploded-tip (basket-tip)
cannula with no suction to separate and mechanically emulsify the
fat. This step comprises 40% of the operating time and addresses
both the superficial and deep fat compartments
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Maintenance IVF should be administered up to 5 L. Every 1 mL
of aspirate beyond 5 L should be replaced with 1 mL of IVE
ب Maintenance IVF should be administered up to 5 L. Every 1 mL
of aspirate beyond 5 L should be replaced with 0.25 mL of IVE
Adiposity is usually focused at the posterior third of the
arm and can be addressed through access points on the distal radial
side of the arm
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the medial antebrachial nerve pierces the fascia of the arm approximately
14 cm proximal to the medial epicondyle and is susceptible to injury
in this area
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Lipodystrophy of the back tends to result in folds, especially inferior to the bra line. Improved contour can be obtained when
the fibrous attachments creating the folds are disrupted
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UAL is a commonly
employed technique for The buffalo
hump
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Lipodystrophy in the abdomen is predominantly in the infraumbilical region
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female
aesthetic having an hourglass figure defined by the flanks and a
slight supraumbilical concavity and infraumbilical convexity
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Men
should have no flare at the iliac crest and the infraumbilical area
should be flat
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In a leaner patient, improved body contour can be achieved with
high definition liposuction or etching
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With this method, the fat in the
superficial plane is liposuctioned to improve or provide the appearance ofmuscular definition
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This techniquecan be usedin conjunction
with focused fat transfer
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In women, the adipose deposits are commonly in the hip overlying the iliac crest and extending down to the lateral thigh zone of
adherence. In contrast, the men tend to have adiposity in theflank or
lateral lumbar area.
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The thigh is a difficult area for liposuction why?
because ofthe circumferential approach that is usually required.
In addition, zones of adherence and natural creases (gluteal crease)
need to be recognized and appreciated. Overzealous suctioning in the
buttock can result in ptosis and in the thigh can lead to unflattering
skin redundancy
The dressing can be changed as needed for drainage and the
compression garment should be worn at all times except during showering. post operatively
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wear compression garments mosta dvocate a duration of 12 weeks
F duration of2 to 4 weeks
VTE is one of the early complication of the Liposuction
T the most common cause of death following liposuction.
Risk for this complication increases with large-volume aspirate
(>5 L), increased wetting solution infiltration
Late Complications
Neurapraxia Should resolve within 3 to 4 months
Contour irregularities
Contour irregularities : thisis the most common postoperative complication and can occur in up to 20% ofpatients.
Techniques to help
prevent include use ofsmall cannulas, multipleaccess incisions, and
cross-tunneling. Treatment of irregularities requires secondary fat
equalization and fat grafting to oversuctioned regions, ifneeded
The abdominal wall is composed ofseven layers
■ Skin
■ Subcutaneous fat (superficial layer offat-thicker and dense)
■ Scarpa fascia (superficial fascia! system)
■ Subscarpal layer (deep layer offat-less dense)
■ Anterior rectus sheath
■ Muscle
■ Posterior rectus sheath
The aponeurotic portion ofthe oblique muscles and the transversus abdominis envelope the rectus muscles forming the anterior and
posterior rectus sheaths
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Huger zones
■ Zone I is the midabdomen, supplied by deep superficial and deep
inferior epigastric arcades.
■ Zone II is the lower abdomen and is supplied by the superficial
and deep circumflex arteries.
■ Zone III is the lateral abdomen and is supplied by the intercostal,
subcostal, and lumbar arteries.
Prior to abdominoplasty, the major blood supply to the abdomen
is from zone II
F Prior to abdominoplasty, the major blood supply to the abdomen
is from zone I
Following abdominoplasty, zone I blood supply is lost
and the abdominoplasty flap is predominantly supplied via zone III
segmental perforators with minor collateral flow from zone II
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Which nerve at risk of injury in abdominoplasty
the lateral femoral cutaneous nerve
emerges into the superficial plane approximately 2 cm medial to the
anterior superior iliac spine (ASIS) and therefore, dissection in this
area should be superficial to reduce the risk of meralgia paresthetica,
a syndrome characterized by tingling, burning, and numbness in the
lateral thigh.
Ilioinguinal nerve injury
at Lateral aspect oflow horizontal incision near inguinal ligament
Numbness along the medial thigh and scrotum/labia
lntercostal injury at Plane between the internal oblique and transversus abdominis. Lateral branches penetrate fascia at midaxillary line and travel
in subcutaneous tissues
T Numbness in
abdominal/flank
dermatome
The blood supply to the umbilicus
The blood supply is based on the subdermal plexus, the ligamentum teres remnant, and perforators from the deep inferior epigastric system.
Patients should be
nicotine free for a minimum of4 weeks prior to and after an abdominoplasty to minimize postoperative complications.
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The amount and location ofexcess fat and skin will aid in determining the best technique to address the abdomen.
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striae will improve with abdimino plasty
F abdominoplasty will remove stria located
inferior to the umbilicus but those located supraumbilically may be
made worse by the procedure
Scars may limit the movement of the
abdominal skin flap and a subcostal scar has potential to compromise
the vascular supply to the skin flap
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Examination ofthe patient
assessment of myofascial laxity via a diver’s test (worsening lower abdominal fullness with flexion at the waist)
a pinch test (assessing abdominal fullness with the abdomen both relaxed and tensed).
When the patient is supine, tensing of the abdominal muscles with a small sit-up should reveal a diastasis rectus if present
The lower excision should be at least 5 to 7 cm above the vulvar commissure and should
be below any cesarean scar ifpossible.
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The upper marking is made based
on pinch test of the abdomen both centrally and laterally. This marking
should come with the level of the ASIS to minimize visibility
F The upper marking is made based
on pinch test of the abdomen both centrally and laterally. This marking
should come down inferior to the ASIS to minimize visibility
abdominoplasty is the procedure with the highest frequency of
death due to pulmonary embolism (PE)
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some studies have found foregoing drains with the use of progressive tension sutures is safe and
without increased risk ofseroma formation
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the position of the umbilicus remains unchanged In the mini abdominoplasty
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dog-ears can be problematic mini abdominoplasty because of the shorter incision
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the high lateral tension abdominoplasty
endorses an oblique vector of pull of the abdominal skin flap
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Benefit of Lockwood tech?
The
oblique vector aids in reducing the horizontal epigastric laxity
In this
technique, more skin is excised from the abdominal skin flap laterally
than centrally.
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Fleur-de-tis procedure is best for a patient who has both
horizontal and vertical skin and tissue excess that is commonly the
case in a weight loss patient
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Care must be taken to only undermine to
the degree necessary for skin resection
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The addition ofliposuction
to the lateral abdomen will result in a discontinuous undermining
that will aid in increasing excursion of the abdominal skin flap laterally without increasing the risk of vascular compromise to the
skin flap.
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Lipoabdominoplasty this abdominoplasty technique substitutes liposuction of the abdominal skin flap in stade of wide lateral
undermining in an effort to preserve perforating vessels
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Undermining of the skin flap is
limited to the area that will be plicated
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Liposuctioning ofthe undermined regions ofthe flap could result in
skin flap necrosis and must be avoided or performed with extreme
caution
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patient maintain a semiflexed position at the
waist, even when ambulating, for several weeks duration to minimize
tension at the closure.
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A compression garment is worn by the patient for several weeks duration
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The patient
should avoid heavy lifting and vigorous activity for up to 6 weeks
postoperatively
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Low molecular weight heparin or other anticoagulant should be
given to those patients deemed to be at higher risk when performing
risk stratification
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Measurs to decrease the incidance of hypertrophic scar
Intraoperatively, wound eversion and minimization of excess tension have been proven to improve scar appearance.
In addition, the use of dermal sutures with a self-adherent mesh and
octyl-2-cyanoacrylate
use of dermal sutures with a self-adherent mesh and
octyl-2-cyanoacrylate (PRINEO, Ethicon, Raleigh, NC) has been
shown to provide better scar results than dermal sutures,
F use of dermal sutures with a self-adherent mesh and
octyl-2-cyanoacrylate (PRINEO, Ethicon, Raleigh, NC) has been
shown to provide equivalent scar results as dermal sutures, and a
subcuticular stitch and is more than four times faster to perform
hypertrophic scars managment
pressure garments, scar massage, and pulsed-dye lasers can improve
the appearance
Complicationsof abdominoplasty, however, do occur but are usually
minor
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More significant complications can include persistent seroma,
areas of flap ischemia, and larger areas of wound dehiscence
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Seroma
is a common problem with abdominoplasty
because of the larger area
that is usually undermined
Measur to decrease the incidance of seroma
progressive tension sutures or quilting sutures has been shown to reduce
dead space and in turn lessen the frequency of seroma formation.”·”
The use of drains and compression garments may also reduce the
incidence of seroma
Most serous complication
These include VTE and PE, large hematomas, infection, and large
areas of flap necrosis.
high risk of VTE thought to be attributable to the tightening of the abdominal wall, which may increase
intra-abdominal pressure.
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all patients should undergo a
thorough risk assessment, and mechanical and chemoprophylaxis
should be utilized.
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Infection is not a frequent abdominoplasty complication
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Complications can occur with any surgical
procedure.
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belt lipectomy is a high yield surgery because it is a circumferential procedure that addressed multiple anatomic areas including the abdomen,
back, flanks, and thighs.
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Commonly, in the weight loss patient, zones
of adherence as well as a midabdominal fascia! thickening are
preserved
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Weight loss before surgery should be stable for
a minimum of 3 months prior to surgical interventions
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The abdomen
should be examined for the presence of hernias. A CT scan can be
ordered if needed in preperatin of belt lipectomy
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with this procedure(LIPECTOMY ), the fascia! zones of
the trunk and lower extremity are not markedly disrupted
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This limits the ability of this procedure to substantially address the thighs,
and patients with concerns in this area may be better served with
a lower body lift
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The goals of the belt lipectomy
are to eliminate the ptotic panniculus to define the waist, eliminate
lower back rolls, and elevate the lateral thighs and mons pubis
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The posterior markings should be based on pinch test both
in the erect and flexed at the waist positions to ensure the area is not
overresected. The proposed line of closure is then marked by ensuring that it is at or above the ASIS so tl1e scar can be hidden with
undergarments
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Because of intraoperative positioning changes, padding of extremities to prevent neurapraxias is of utmost importance in lipectomy
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The dissection is carried up to the xiphoid similar to
that with abdominoplasty
with the exception that the lateral area
is undermined to a greater degree.
Little to
no undermining of the superior or inferior skin flaps is performed.
To optimize the superior excursion of the lateral thigh and minimize
contour irregularities
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the lateral thigh liposuctioned in a discontinuous
manner to partially disrupt the pelvic rim zone of adherence
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Superficial wound healing problems and minor wound dehiscence are the most common complications that
occur with circumferential body contouring procedures such as
the belt lipectomy because of the competing tensions of the anterior and posterior incisions.
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Seroma formation can be minimized by
only undermining the tissues to the degree necessary for excision
and closure
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measures such as sharp dissection, closed suction
drains, and quilting or progressive tension sutures are also proven to
reduce seroma rates.
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Untreated seromas can lead to infections
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Skin flap necrosis can also
occur in the belt lipectomy patient and this is usually due to excessive tension, previous incisions that compromise regional blood
flow, and aggressive liposuction.
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Procedures that tighten the
abdominal wall, such as recuts plication, are theorized to increase
intra-abdominal pressure, which affects the compression susceptible
venous system
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Nonessential supplements and vitamins should be discontinued
3 weeks prior to surgery
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Zones of adherence are recognized regions in which the subcutaneous tissues are securely adherent to the deep fascia.
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Zones of adherence
■ Gluteal crease
■ Lateral gluteal depression
■ Middle medial thigh
■ Distal iliotibial tract
■ Distal posterior thigh
At minimum, patients undergoing liposuction should have pneumatic compression stockings in place
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The wetting solution has multiple functions and aids with
anesthesia, hemostasis, and emulsification of adipocytes
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SAL is more labor-intensive and does not perform as well on
areas with fibrous fat.
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Because PAL can break up fibrous fat more readily, this modality can significantly cut down on physician fatigue
due to shorter procedure times and employing less physical labor
to use
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UAL works to emulsify the fat by three
mechanisms
■ Mechanical: direct tissue effects by the ultrasound wave; this is the
primary mechanism
■ Cavitation: tissue fragments based on the formation and collapse
ofintracellular microbubbles
■ Thermal: absorption of the ultrasound waves produces heat
LAL uses a small laser fiber to emulsify fat and tighten skin
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A
four-step technique is used in LAL
- Infiltration
- Application of energy to the tissue
- Evacuation
- Subdermal skin stimulation
Primary endpoints
■ SAL/PAL: contour, symmetrical pinch test, and presence of
bloody aspirate
■ UAL: loss of tissue resistance, contour, and presence of bloody
aspirate
Secondary endpoints
■ SAL/PAL/UAL: treatment time and volume
The SAFE Benefits
■ Optimize fat removal
■ Provide comprehensive means of body contouring
■ Preserve vascular integrity
■ Maximize skin retraction
■ Minimize potential for complications/revisions
Early Complications of liposuction
Inadequate fluid resuscitation
Sinus tachycardia
Injury to solid organs, bowel, or blood vessels:
Hypothermia
Skin slough
VTE
LAST (local anesthetic system toxicity)
Late Complications of liposuction
Neurapraxia
Contour irregularities
Pregnancy and weight gain can
result in a separation of the rectus muscles in the midline termed a
diastasis rectus
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The umbilicus is located at or near the mid.line at the level of the
iliac crests
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The
ideal umbilicus has superior hooding, round or oval shape, is shallow,
and has inferior retraction.
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Usually
no plication ofthe rectus muscles is performed. in Miniabdominoplasty
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The tension at the line of closure is borne by meticulous closure of the superficial fascia) system (Scarpa fascia in High Lateral Tension
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the liposuction with a
superwet technique is performed in the areas lateral to the rectus
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Complicationsof abdominoplasty, however, do occur butareusually
minor and may include small areas of wound healing problems, poor
scars, and lateral dog-ears. Small areas of wound dehiscence, suture
abscess,
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More significant complications can include persistent seroma,
areas of flap ischemia, and larger areas of wound dehiscence
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Larger areas
of wound dehiscence can be allowed to heal via secondary intention
and be revised at a later date
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all patients should undergo a
thorough risk assessment, and mechanical and chemoprophylaxis
should be utilized.
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Infection is not a frequent abdominoplasty complication
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the fascia! zones of
the trunk and lower extremity are not markedly disrupted in BELT LIPECTOMY
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The
posterior incisions are made based on tailor-tacking and a cut as you
go technique, if that is the surgeon preference to prevent overreaction. in belt lipoctemoy
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The
genitofemoral nerve courses deep into the abdominal wall
and originates from Ll to L2
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Lidocaine toxicity is best treated with 20% lipid
emulsion.
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Treatment of LAST
I. Infuse 20% lipid emulsion. (Upper limit is approximately 10-12 mL/kg over the first 30 minutes.)
2. Bolus at 1.5 mL/kg (lean body mass) intravenously over 1 minute.
3. Provide continuous infusion at 0.25 mL/kg per minute.
4. For persistent cardiovascular collapse, repeat bolus up to two times.
5. Double the infusion to 0.5 mL/kg per minute, if remains
hypotensive.
6. Continue infusion for at least IO minutes after circulatory
stability is achieved.
Skin turgor and the
fountain sign are endpoints for infiltration of wetting
solution
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The resultant scar from a belt lipectomy is generally located more superior than that of a lower body lift
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To obtain maximal lift from the belt lipectomy, the zones of adherence of the
lateral thighs are discontinuously disrupted with liposuction
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