Liposuction: 

Indications: removal of localized excess adipose tissue in areas with good overlying skin quality and minimal excess skin. All patients being evaluated for liposuction should be within 30% of the ideal body weight and should have reasonable expectations regarding results of liposuction. 

Anatomy: 

• The adipose tissue in the area can be divided into two layers: superficial and deep

• Superficial layer is 1-2mm below dermis and is dense and compact –> superficial liposuction can create contour irregularities
• Deep layer is loose and aerolar with few septa –> conventional liposuction performed here

• Zone of adherence: 

• Definition: areas where the subcutaneous tissue is known to be securely adherent to the underlying fascia. Liposuction should be avoided in these areas of prevent contour irregularities. 
• Areas: 

• The gluteal crease
• Lateral gluteal depression
• Middle medial tigh
• Distal iliotibial tract
• Distal posterior thigh

Liposuction technique: 
There are several different types of liposuction techniques 

• SAL – suction assisted liposuction 
• PAL -power assisted liposuction 
• UAL – ultrasound assisted liposuction 

• LAL – laser assisted liposuction 

PAL and UAL have been shown to reduce surgeon fatigue. Laser assisted liposuction as the theoretical improvement in skin tightening and has been shown to decrease pain postoperatively

Tumescent Solution: 
Regardless of the technique used, the procedure starts with infiltration of tumescent solution. This is typically 30-55mg/kg lidocaine in tumescent.

• Dry: no tumescent- can cause blood loss up to 45% of aspirate
• Wet: 200-300mL of solution per anatomic area to be treated
• Superwet: 1:1 ratio of solution instilled to aspirate
• Can have blood loss in 1% of aspirate
• Tumescent: 2:1 to 3:1 of wetting solution per mL of aspirate
• Can have blood loss in 1% of aspirate
• Between 10-30% of local anesthetic is present in the aspirate

Postoperatively: 

• Discharge:
• Most patients go home the same day 
• Large volume aspirate includes >5L, consider these patients for overnight observation 

Complications: Risk factors for complications in suction lipectomy include: aspiration of large amounts of tissue, increased volume of tumescent infiltration, concomitant procedures

• Lidocaine toxicity: 
• Peak  levels occur at 8-18 hours after infiltration. 
• Early findings include perioral numbness, tinnitus, metallic taste, anxiety, muscle twitching, and seizures. 
• Late Findings: cardiovascular including tachycardia and hypertension that can progress to ventricular arrhythmias and ultimately asystole. 
• Treatment includes advanced cardiac life support and administration of a bolus of 20% lipid emulsion
• Fat embolism: rare complication after liposuction
• Presentation:  respiratory distress, cerebral dysfunction (alteration in mental status), and petechial rash –> typically commence 24-72 hours

Long term results:  Level III evidence reveals that removal of excess fat through liposuction results in long term reduction of fat in treated areas without fat re-accumulation in either treated or untreated areas of the body (if the patient does not gain weight). 

Gluteal Fat Grafting: 

Complications: 

• Gluteal fat grafting does have a higher mortality with this than any other aesthetic operation. 
• Mortality is mainly due to fat pulmonary embolism due to a mechanical tear of a large gluteal vein followed by either intravascular injection of fat or migration of extravascular fat into an injured vein by pressure gradient 

Safety measures: 

• avoid injecting into the muscle, use single hole cannula >4.1mm, avoiding downward angulation of the cannula, only injecting when the cannula is in motion

Cryolipolisis: 

Definition: Cryolipolysis or Coolsulpting as a non-surgical way to reduce localized adipose tissue. 

Technique: 

• This technique sets targeted areas at 44 degrees Fahrenheit for a preset period of time–> targets adipocytes. 
• Induces apoptosis of adipocytes via cellular edema, increased inflammation. Inflammatory cell peak infiltrates peak at 30 days

Complications: 

• Paradoxical adipose hyperplasia (PAH): 
• Definition: known complication of cryolipolysis, where the area treated has increase in adiposity
• Associations: use of large applicator, male sex, Hispanic background, abdominal location of treatment
• Treatment is power assisted liposuction
• Transient Hypoesthesia – typically resolves within several weeks. 

Abdominoplasty: 

Definition: A well-established  cosmetic  surgery  procedure  for  improving  body  contour  by  means  of  re-moving excess skin, subcutaneous fat, and soft tissue from the  abdomen  and  restoring  musculofascial  integrity  and  skin  elasticity. 

Regional Anatomy: 

• The central abdominal wall is composed of seven layers 
• Skin
• Subcutaneous fat
• Scarpas fascia (which provides the strength layer at the time of closure)
• Subscarpal layer
• Anterior rectus sheath
• Rectus abdominis muscles
• Posterior rectus sheath. 

• Regional Muscles: 4 paired muscle groups that make up the abdominal wall including: 
• Centrally: the rectus abdominis centrally 
• Laterally: external oblique, internal oblique and trasversus abdominis

• Linea alba: The aponeurotic portions of the oblique muscles and transversus make up the anterior and posterior rectus sheaths which come together in the midline called the linea alba. With weight gain and pregnancy there can be a separation of the rectus muscles at the linea alba called rectus diastasis which is not a hernia but can cause a midline bulge. 

• The regional blood supply to the abdomen is from three zones:

• Zone 1: is the midabdomen which is supplied by the DIEA 
• Zone 2: in the lower abdomen which is supplied by branches of the external iliac including the superficial and deep circumflex arteries 
• Zone 3: is the lateral abdomen which is supplied by the intercostal, subcostal, and lumbar arteries
• **Prior to abdominoplasty the major blood supply to the abdomen is from Zone 1, Following abdominoplasty the blood supply is from zone 3

• Regional Nerves: 
• Lateral femoral cutaneous nerve: 
• Anatomy:  Becomes superficial about 2cm medial to the ASIS. Dissection in this area should be superficial in order to avoid injury to this nerve. 
• Injury: leads to numbness of the lateral thigh
• Diagnosis of injury: injection of local anesthetic and Tinel’s sign 
• Treatment: conservative or surgical depending on patient’s symptoms

• Other nerves at risk for injury include the iliohypogastric, ilioinguninal and intercostal nerves. Of note the genitofemoral nerve courses deep to abdominal wall and pierces fascia below the inguinal ligament supplying pubic region thus not at risk for injury during an abdominoplasty

Preoperative Screening: 

• History: 
• Prior abdominal surgeries
• Pregnancy and planned pregnancy 
• Tobacco use 

• Exam: 
• Presence of hernias. If the patient has a hernia that needs repair or other potential intra-abdominal surgeries. These can be safely performed with abdominoplasty. 

Operative Technique: 

• Traditional abdominoplasty: 
• Definition:  includes elevation of the abdominal flap and advancing to lower incision for skin and fat removal. Typically rectus plication is completed above and below the umbilicus. Umbilicus is telescoped through the abdominal flap at the level of the iliac crests

• Mini- abdominoplasty or short scar abdominoplasty:
• Definition: excision of lower abdominal skin/soft tissue without transposition of the umbilicus or rectus plication.  

• Fleur-de-lis abdominoplasty: 
• Definition: excision of skin the vertical and horizontal plane. 
• Use: best employed for patients with both vertical and horizontal skin laxity and includes both a horizontal scar and vertical scar. 

For all abdominoplasty techniques – Progressive tension sutures can be placed from scarpas fascia to abdominal wall fascia. This helps close dead space, minimize flap movement, minimize seroma rate, minimize tension on closure

Postoperative Care: 

• Pain control: 
• TAP blocks (transversus abdominal plane blocks): 
• Definition: Block to the intercostal nerves
• Anatomy: The intercostal nerves course between the transversus and the internal abdominal oblique muscles. Blocking the nerves at this level can provide reliable pain control to T7-L1 dermatomes with the highest level of anesthesia at T10. 

Complications: 

• VTE and PE: 
• Abdominoplasty carries an increased risk of VTE. Therefore all patients should be evaluated using the Caprini risk assessment model. Any patients undergoing a plastic surgery procedure longer than 60 minutes should undergo prevention. 

• Seroma: 
• Most common complication after abdominoplasty and abdominoplasty plus liposuction. 
• Prevention:  by placing progressive tension sutures and or the use of drains
• Treatment: start with aspiration, then placement of a closed suction drain. If that does not work use of a sclerosing agent or operative resection of the seroma cavity can be considered. 

• Areas of flap ischemia or skin necrosis: 
• Skin necrosis is most likely to occur in the suprapubic area 
• Concurrent liposuction might further disrupt the blood supply to this area especially in the supraumbilical region due to disruption of the subcostal and intracostal blood supply to the skin. 

Many patients request that abdominoplasty occur in conjunction with other cosmetic procedures. Hoever, base of Dr. Grotting’s data – rates of complications increase with additional procedures. 

• Abdominoplasty alone 3.1%
• abdominoplasty with liposuction (3.8%)
• abdominoplasty with breast procedure (4.3), + liposuction (4.6%)
• abdominoplasty + body contouring procedure 10
• abdominoplasty +body contouring +breast =12%

Lower Body Lift: 

Definition: 

• Surgeons offer a lower body lift to circumferentially address excess skin and soft tissue in multiple areas including the abdomen, back, thighs and buttock. 

Surgical Procedure: 

• Buttock lift – minimally undermining in the prone position
• Lateral thighs –  mobilize the lateral thighs for lifting the tissue must be loosened from the underlying TFL and muscular fascia. 
• Technique of releasing zone of adherence: discontinuous manner in order to maintain neurovascular supply to the skin and prevent seroma formation as described by Lockwood. Release in the lateral gluteal depression area is found to be most effective in allowing the advancement of flaps in the lower body lift 
• Abdominoplasty: flip the patient supine in order to perform the abdominoplasty portion of the case as described above. 

Complications:  

• Seroma: This is the most common complication. 
• Hematoma: male gender is an increased risk factor for hematoma and seroma in patients independent of other co-morbidities

Brachioplasty: 

Definition: body contouring procedure often done in bariatric surgery patients who demonstrate laxity and tissue excess of the arms following weight loss. 

Cause of excessive arm skin laxity: Laxity of skin is caused by loosening of the clavopectoral fascia –> lies deep to the pectoralis major muscle and extends from the clavicle to the dome of the axillary fascia

Related Anatomy: 

• Two sensory nerves: superficial to the deep fascial layer and are thus at risk of injury during a brachioplasty. These include the medial brachial cutaneous nerve and the medial antebrachial cutaneous nerve. 
• Medial brachial cutaneous nerve: 
• Innervation: medial aspect of the upper arm 
• MABC :
• Innervation:  medial side of the upper arm and the ulnar forearm. 
• Anatomy: commonly injured of the two given that it pieces the deep fascial 14cm proximal to the medial epicondyle and travels with the basilic vein in the superficial plane. Damage to this nerve can cause medial forearm sensory loss. Recommended technique to protect MABC is to leave a 1cm cuff of fat overlying the deep fascia

Techniques: 

• Liposuction:  
• Use: Minimal skin laxity with skin pinch <1.5cm and mild to moderate amounts of adipose tissue liposuction can be performed as a stand alone technique
• Mini-brachioplasty: 
• Use: For patients with good skin quality and a moderate amount of excess skin and adipose tissue. This technique will have limited to no benefit for MWL patients 
• Technique:  brachioplasty limited to the proximal half to one-third of the arm can be considered. 
• Traditional or extended brachioplasty: 

• Use: patients with excessive skin laxity and adipose tissue
• Technique:
• The superior incision is often placed 1 fingerbreadth above the bicipital groove and the inferior incision is based on the pinch test. 
• This technique can be combined with liposuction. Performing liposuction in conjunction with brachioplasty aids in tissue dissection (decreases risk for nerve injury and lymphedema). Does not increase wound complications
• Importantly anchoring the arm flap should be anchored to the  axillary fascia to prevent widening of the scar Posteromedial incision has been shown to minimize tension on the surgical incision, which leads to better scarring and less visibility of arm scars

Complications:

• Most common complication is widened, hypertrophic scars –> additionally this is the most common reason for additional surgery (scar revision)
• Most common complication of liposuction of the arm is contour irregularities

Thighplasty: 

Use: This addresses medial thigh excess skin and soft tissue. 

Techniques: Include both transverse and full length vertical thighplasty 

• Suspension: suspend the thigh flap to the superficial fascial system (colles fascia in the thigh) to prevent complications such as widening and inferior migration of scars, traction deformity of the vulva, and early recurrence of thigh ptosis

Complications: 

• Most common: prolonged edema due to circumferential compression of the low-pressure lymphatic system

Massive Weight Loss Patients: 

Considerations for Nutritional Status: 

• In patients who have undergone gastric bypass surgery, consensus recommendations are to wait to proceed with body contouring surgery until the patient is at least 1 year from surgery and until the patient has had stable weight for 3-6 months
• Nutritional status:  
• Protein: Minimal 60-100g daily is necessary to prevent malnutrition and avoid delayed wound healing in patients
• Iron deficiency: most common nutritional deficiency (in 30-50% of patients) and should be evaluated with CBC
• Thiamine or B1 deficiency: present as postoperative confusion (Wernicke encephalopathy)