Body Contouring

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

• Techniques:
• liposuction versus skin excision (full length posterior or posteromedial incision or minimal incision brachioplasty). Skin laxity is the greatest determinant of whether liposuction vs excision or both
• Pinch test –> if >1.5cm liposuction is an appropriate option
• Skin laxity with little fat is treated with direct excision
• Skin laxity and lipodystrophy treated with combination
• 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
• Procedure includes liposuction or skin and fat removal followed by anchoring the arm flap to the axillary fascia to prevent widening of the scar (arm dermis to axillary dermis to axillary fascia)
• Posteromedial incision has been shown to minimize tension on the surgical incision, which leads to better scarring and less visibility of arm scars
• Performing liposuction in conjunction with brachioplasty aids in tissue dissection (decreases risk for nerve injury and lymphedema). Does not increase wound complications.
• 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
• Medial antebrachial cutaneous nerve injury: can cause medial forearm sensory loss
• Nerve branches around the basilic vein in the distal third of the forearm –> nerve penetrates deep fascia approximately 14cm proximal to the medial epicondyle
• Recommended technique to protect MABC is to leave a 1cm cuff of fat overlying the deep fascia

Crylolipolysis: cold induced panniculitis (Coolsculpting, nonsurgical). 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
• Paradoxical adipose hyperplasia (PAH): known complication of cryolipolysis, where the area treated has increase in adiposity
• Use of large applicator, male sex, Hispanic background, abdominal location of treatment
• Treatment is power assisted liposuction
• Complications: most common complication is transient hypoesthesia- resolves in 6 months

Liposuction

• Subcutaneous fat of abdomen divided into 2 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
• Tumescent Infiltration: dose 30-55mg/kg lidocaine in tumescent. Peak levels occur at 8-18 hours after infiltration.
• 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
• Zones of adherence: zones where superficial fascial system sends elements through the deep compartment attaching to the investing fascia of the underlying musculature
• Lateral gluteal depressinon, iliotibial tract, gluteal crease
• Level III evidence reveals that removal of excess fat through liposuction results in long term reduction of fat in treated areas without fat reaccumulation in either treated or untreated areas of the body (if the patient does not gain weight)
• Suction assisted liposuction vs ultrasonic-assisted liposuction: main advantage of UAL is less surgeon fatigue. No studies have show consistent clinical benefits for UAL over SAL
• Laser assisted liposuction has been shown to decrease pain postoperatively
• Large volume aspirate includes >5L, consider these patients for overnight observation
• Complications:
• Lidocaine toxicity: early findings include perioral numbness, tinnitus, metallic taste, anxiety, muscle twitching, and seizures. Cardiovascular findings include 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 that presents with three classical symptoms: respiratory distress, cerebral dysfunction (alteration in mental status), and petechial rash –> typically commence 24-72 hours
• Most common cause of death associated with suction lipectomy is VTE. Risk of death is highest with lipoplasty is combined with abdominoplasty
• Risk factors for complications in suction lipectomy include: aspiration of large amounts of tissue, increased volume of tumescent infiltration, concomitant procedures

Gluteal fat grafting: higher mortality with this than any other aesthetic operation

• Most deaths occur by pulmonary embolism
• Most common causative mechanism is 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

Panniculectomy: 

• Medicare/medicaide guidelines for approval include 1) inability to walk normally, 2) chronic pain/ulceration created by abdominal skin fold 3) when panniculus hangs below level of pubis 4) interigo recurrent over 3 month period 5) stable weight loss for at least 6 months and 18 months after GB surgery

Abdominoplasty

• Includes elevating abdominal flap and advancing to lower incision for skin removal 
• Skin and fat removed
• Typically rectus plication is completed above and below the umbilicus 
• Umbilicus is telescoped through the abdominal flap at the level of the iliac crests
• Patients with both vertical and horizontal skin laxity are candidates for a corset or fleur de lis abdominoplasty
• Progressive tension sutures are placed from scarpas fascia to abdominal wall fascia and helps close dead space, minimize flap movement, minimize seroma rate, minimize tension on closure
• Another common method for decreasing tension is to closure the native umbilical skin opening in the vertical direction
• Zones of abdominoplasty: 1: mid abdomen, supplied by DIEP 2: lower abdomen supplied by external iliac 3: lateral abdomen supplied by intercostals 
• You can perform intra-abdominal surgeries plus abdominoplasty safely
• Innervation of the abdominal wall includes the anterior cutaneous branches of the 6-12 intercostal nerves –> severed during undermining of the abdominal flap
• Nerves at risk include iliohypogastric, ilioinguinal nerves, intercostal nerves. 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.
• TAP (transversus abdominal plane) block: intercostal nerves course between transversus and the internal abdominal oblique muscles –> may block at this level to provide pain control
• Reliable block of t10 to L 1 dermatomes when lateral approach from the triangle of petit is used
• VTE using the Caprini risk assessment model: abdominoplasty carries the greatest 
• ASPS VTE task force recommends those undergoing elective plastic surgery who have score of 7 or greater to have VTE risk reduction strategies: limiting OR time, weight reduction, discontinuation of hormone therapy, early postoperative mobilization, consider extended use of LMWH
• Major plastic surgery cases (>60 minutes) should undergo prevention
• Highest risk factors include age >75, DVTPE hx, Positive factor V leiden, HIT, elevated anticardiolipin or serum homocysteine or prothrombin or lupus anticoagulant, congenital or acquired thrombophilia, family hx of thrombosis
• Complications: 
• Seroma is the most common complication after abdominoplasty and abdominoplasty plus liposuction –> this is prevented by placing progressive tension sutures and or the use of drains
• If serial aspiration does not resolve seroma–> place closed suction drain –> sclerosing therapy –> operative ID
• Rate of complications (based on Grotting’s data) 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%
• Hematoma highest complication at 1/3 of all reported complications
• Area for least return of sensation involves below the umbilicus and above the incision (infraumbilical)
• Supraumbilical abdomen has been considered the area where liposuction might further disrupt blood supply already interrupted by abdominoplasty undermining (this is prior to advancement); avoid liposuction centrally if performing in conjunction (zone 1!!!)
• Skin necrosis likely to occur in the subrapubic area as blood supply to the abdominoplasty is derived from the lateral interstitial vessels (corresponds to supraumbilical area prior to advancement
• Supraumbilical bulge: can be caused by failure to plicate the rectus muscle
• LFCN (lateral femoral cutaneous nerve injury): nerve exits the abdomen near the anterior superior iliac spine and is the most commonly injured nerve in abdominoplasty –> signs and symptoms include anterior and lateral thigh burning, tingling, and or numbness–> diagnosis can be confirmed with injection of local anesthetic and Tinel’s sign –> treatment is conservative or surgical depending on patients symptoms

Lower Body Lift: 

• Requires continuous or discontinuous release of the lateral gluteal depression to be the most effective in allowing the advancement of flaps in the lower body lift
• Must assess nutritional status in MWL patients
• Complications:
• Seroma: common complication. Treatment strategies include percutaneous aspiration, drainage, and injection of sclerosant agents (doxycycline and bleomycin)
• Hematoma: male gender is an increased risk factor for hematoma and seroma in patients independent of other co-morbidities

Thighplasty: 

• Techniques include transverse and full length vertical thighplasty 
• It is important to 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:
• For full length thighplasty, most common complication is prolonged edema due to circumferential compression of the low pressure lymphatic system

Massive Weight Loss Patients: 

• 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
• Gastric bypass has been showing to be associated with higher rates of surgical complications following body contouring than other weight loss methods
• Nutritional status in bariatric patients: deficiencies in calcium, vitamin B12, folate, and thiamine
• Minimal 60-100g daily of protein is necessary to prevent malnutrition and avoid delayed wound healing in patients
• Iron deficiency is most common nutritional deficiency (in 30-50% of patients) and should be evaluated with CBC
• Thiamine or B1 deficiency can present as postoperative confusion (Wernicke encephalopathy) 
• Most common complication following body contouring for post- MWL patients is seromas (treatment under abdominoplasty)

Miscellaneous

• Barbed Sutures: studies show decreased operative time
• If patients have history of familial VTE, recurrent miscarriages –> consultation with hematologist recommended as genetic thrombophilia likely cause and patients will have higher risk of VTE with body contouring procedure
• Most common inherited thrombophilia is factor V Leiden –> present in 3-7% of individuals –> due to increased resistance of protein C 
• Submental liposuction: if marginal mandibular weakness occurs –> observe. Nerve injury reported to be less than 1%
• Remember the marginal mandibular nerve is typically positioned above the inferior border of the mandible in 81% of patients, can be below in 19% of patients
• Normal body temperature during surgery specifically reduces likelihood of surgical site infections and reduces the risk of bleeding