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PART IX
Body Contouring
57. Liposuction
Adam Jacoby, Simon Moradian
See Essentials of Aesthetic Surgery, pp. 799–817
CLINICAL CONSIDERATIONS
1. What is the maximum safe dose of lidocaine used in tumescent solution for liposuction?
A. 2 mg/kg.
B. 4 mg/kg.
C. 7 mg/kg.
D. 14 mg/kg.
E. 35 mg/kg.
CLINICAL CONSIDERATIONS
2. What symptom of lidocaine toxicity is observed first, at the lowest plasma concentration of anesthetic?
A. Tinnitus.
B. Tremors.
C. Coma.
D. Cardiac arrest.
E. Diplopia.
CLINICAL CONSIDERATIONS
3. After patient stabilization, what is the first-line treatment for lidocaine toxicity?
A. Flumazenil.
B. 20% lipid emulsion.
C. Methylene blue.
D. Diazepam.
E. Naloxone.
CLINICAL CONSIDERATIONS
4. What is the minimum volume of lipoaspirate during a single operation that requires overnight monitoring?
A. 2 liter.
B. 3 liter.
C. 4 liter.
D. 5 liter.
E. 7 liter.
CLINICAL CONSIDERATIONS
5. Compared with suction-assisted liposuction, patient undergoing ultrasound-assisted liposuction (UAL) are at
greater risk of which complication?
A. Hematoma.
B. Seroma.
C. Thermal injury.
D. Infection.
E. Contour irregularities.
432 Part IX&Body Contouring
CLINICAL CONSIDERATIONS
6. Which wetting solution technique is defined by a 1:1 ratio of infiltrate to aspirate?
A. Dr y.
B. Wet.
C. Superwet.
D. Tumescent.
E. Subcutaneous clysis.
CLINICAL CONSIDERATIONS
7. What technique can help reduce the risk of creating iatrogenic contour deformities?
A. Cross-hatching.
B. Suction-assisted liposuction.
C. Large cannula size.
D. Superficial liposuction.
E. Use of candy cane port configuration.
CLINICAL CONSIDERATIONS
8. What is considered the true endpoint of ultrasound-assisted liposuction (UAL)?
A. Duration of procedure.
B. Volume of lipoaspirate.
C. Appearance of lipoaspirate.
D. Loss of cannula resistance.
E. Symmetrical pinch test.
CLINICAL CONSIDERATIONS
9. A 36-year-old woman undergoes liposuction of the abdomen and flanks. Liposuction is performed using 2.5
liter of infiltration fluid. Each liter is mixed with 50 mL of 2% plain lidocaine and 1 mL of 1:1000 epinephrine.
At which of the following times after infiltration is concentration of lidocaine in the blood expected to be the
highest in this patient?
A. Immediately after injection.
B. 1 hour after surgery.
C. 3–4 hours after surgery.
D. 8–18 hours after surgery.
E. 20–24 hours after surgery.
CLINICAL CONSIDERATIONS
10. Compared with standard suction-assisted liposuction, what is a benef it of laser-assisted techniques?
A. Decreased postoperative ecchymosis.
B. Decreased dermal thermal injury.
C. Decreased operative time.
D. Decreased surgeon fatigue.
E. Decreased cost.
CLINICAL CONSIDERATIONS
11. A 43-year-old woman is requesting improved abdominal contour. She has had three children and on examina-
tion has lipodystrophy, excessive infraumbilical skin, and a moderate diastasis. Which contouring procedure
would most effectively treat her complaints?
A. Ultrasound-assisted liposuction.
B. Suction-assisted liposuction.
C. Laser-assisted liposuction.
D. Lipoabdominoplasty.
E. Cryotherapy.
Chapter 57&Liposuction 433
Answers
CLINICAL CONSIDERATIONS
1. What is the maximum safe dose of lidocaine used in tumescent solution for liposuction?
E. 35 mg/kg.
The answer is E, 35 mg/kg. The maximum safe doses for lidocaine without epinephrine and with epinephrine
are 5 and 7 mg/kg, respectively. The vasoconstrictive property of epinephrine, slow infiltration, and relative
avascularity of fat allow this value to be relatively higher.
REFERENCES
1. Klein JA. Tumescent technique for local anesthesia improves safety in large-volume liposuction. Plast Reconstr
Surg 1993;92:1085; discussion 1099
2. Ostad A, Kageyama N, Moy RL. Tumescent anesthesia with a lidocaine dose of 55 mg/kg is safe for liposuction.
Dermatol Surg 1996;22:921
3. Lozinski A, Huq NS. Tumescent liposuction. Clin Plast Surg 2013;40:593
4. Matarasso A. Lidocaine in ultrasound-assisted lipoplasty. Clin Plast Surg 1999;26:431
CLINICAL CONSIDERATIONS
2. What symptom of lidocaine toxicity is observed first, at the lowest plasma concentration of anesthetic?
A. Tinnitus.
The answer is A, tinnitus, which occurs at the lowest plasma concentration of toxicity (3 μg/mL). Cardiac
arrest occurs at a much higher plasma level (20 μg/mL), while tremors and coma occur between the two.
1,2,3,4
1
REFERENCE
1. Matarasso A. Lidocaine in ultrasound-assisted lipoplasty. Clin Plast Surg 1999;26:431
CLINICAL CONSIDERATIONS
3. After patient stabilization, what is the first-line treatment for lidocaine toxicity?
B. 20% lipid emulsion.
The answer is B, lipid emulsion, which is bolused at a rate of 1.5 mL/g of lean body mass followed by a continuous infusion of 0.25 mL/kg/min. Flumazenil is a benzodiazepine antagonist used for overdose.
Methylene blue is an antidote for methemoglobinemia and diazepam is a benzodiazepine used to treat alcohol withdrawal.
1
REFERENCE
1. Matarasso A. Lidocaine in ultrasound-assisted lipoplasty. Clin Plast Surg 1999;26:431
CLINICAL CONSIDERATIONS
4. What is the minimum volume of lipoaspirate during a single operation that requires overnight monitoring?
D. 5 liter.
The answer is D, 5 liter of lipoaspirate, which is defined as large-volume liposuction. Monitoring is necessary
due to fluid shifts with a higher potential of volume overload. Patients with >5 liter of liposuction are also at
higher risk of lidocaine toxicity and should be monitored appropriately.
1,2,3,4
REFERENCES
1. Iverson RE, Lynch DJ; American Society of Plastic Surgeons Committee on Patient Safety. Practice advisory on liposuction. Plast Reconstr Surg 2004;113:1478; discussion 1491
2. Weinberg GL. Lipid emulsion infusion: resuscitation for local anesthetic and other drug overdose. Anesthesiology
2012;117:180
3. Rohrich RJ, Leedy JE, Swamy R, et al. Fluid resuscitation in liposuction: a retrospective review of 89 consecutive
patients. Plast Reconstr Surg 2006;117:431
434 Part IX&Body Contouring
4. Commons GW, Halperin B, Chang CC. Large-volume liposuction: a review of 631 consecutive cases over 12 years.
Plast Reconstr Surg 2001;108:1753; discussion 1764
CLINICAL CONSIDERATIONS
5. Compared with suction-assisted liposuction, patient undergoing ultrasound-assisted liposuction (UAL) are at
greater risk of which complication?
C. Thermal injury.
The answer is C, thermal injury, which can lead to burns. Thermal methods of liposuction lessen cannula
resistance and reduce surgeon fatigue. Compared with power-assisted and suction-assisted techniques,
UAL is associated with similar hematoma, seroma, and infection rates.
1,2,3
REFERENCES
1. Rohrich RJ, Beran SJ, Kenkel JM, et al. Extending the role of liposuction in body contouring with ultrasoundassisted liposuction. Plast Reconstr Surg 1998;101:1090; discussion 1117
2. Zocchi M. Ultrasonic liposculpturing. Aesthetic Plast Surg 1992;16:287
3. Kenkel JM, Janis JE, Rohrich RJ, et al. Aesthetic body contouring: ultrasound-assisted liposuction. Oper Tech Plast
Reconstr Surg 2002;8:180
CLINICAL CONSIDERATIONS
6. Which wetting solution technique is defined by a 1:1 ratio of infiltrate to aspirate?
C. Superwet.
The answer is C, superwet technique. “Dry” liposuction uses no infiltrate and is associated with the greatest
estimated blood loss. Wet liposuction uses approximately 200 to 300 mL of wetting solution, yielding a blood
loss of 4 to 30%. Superwet liposuction is the only technique defined by a 1:1 ratio of infiltrate to aspirate while
tumescent liposuction is defined by 1 mL of aspirate per every 3 to 4 mL of infiltrate, yielding the lowest estimated blood loss (Table 57.1). Subcutaneous clysis is not a described method that is commonly used.
Infiltrate may contain lidocaine, epinephrine, and/or sodium bicarbonate, depending on surgeon's
preference.
1
Table 57.1 Wetting Solution Infiltrate and Estimated Blood Loss by Technique
Technique Infiltrate Estimated Blood Loss (as % volume)
Dry None 20–45
Wet 200–300 mL/area 4–30
Superwet 1 mL infiltrate:1 mL aspirate <1
Tumescent 3–4 mL infiltrate:1 mL aspirate <1
REFERENCE
1. Iverson RE, Pao VS. MOC PS (SM) CME article: liposuction. Plast Reconstr Surg 2008;121 (4Suppl): S1
CLINICAL CONSIDERATIONS
7. What technique can help reduce the risk of creating iatrogenic contour deformities?
A. Cross-hatching.
The answer is A, cross-hatching. The use of multiple patient positions and multiple access incisions allows
for a smooth and regular contour after liposuction. Larger cannulas suction a greater amount of fat per pass
and are associated with contour deformities, as is superficial liposuction. Suction-assisted liposuction itself
is not associated with creating contour deformities. Candy cane configuration is generally a more aggressive
canula for liposuction and should be used in the proper plane to avoid contour deformities.
1,2,3
REFERENCES
1. Rohrich RJ, Smith PD, Marcantonio DR, et al. The zones of adherence: role in minimizing and preventing contour
deformities in liposuction. Plast Reconstr Surg 2001;107:1562
2. Neligan P, Warren RJ, eds. Plastic Surgery. Vol. 2. 3rd ed. Philadelphia: Saunders Elsevier; 2013
3. Young VL, Brandon HJ. The physics of suction-assisted lipoplasty. Aesthet Surg J 2004;24:206
Chapter 57&Liposuction 435
CLINICAL CONSIDERATIONS
8. What is considered the true endpoint of ultrasound-assisted liposuction (UAL)?
D. Loss of cannula resistance.
The answer is D, loss of resistance to probe advancement. Although the duration of the procedure and volume of liposuction are both important factors in determining a patient's fluid balance, they are not considered true endpoints. The appearance of lipoaspirate (especially if sanguinous) is often considered an
accepted endpoint for standard suction-assisted liposuction. Symmetrical pinch test is considered an
acceptable endpoint for suction-assisted or power-assisted liposuction.
1
REFERENCE
1. Matarasso A. Lidocaine in ultrasound-assisted lipoplasty. Clin Plast Surg 1999;26:431
CLINICAL CONSIDERATIONS
9. A 36-year-old woman undergoes liposuction of the abdomen and flanks. Liposuction is performed using 2.5 liter of
infiltration fluid. Each liter is mixed with 50 mL of 2% plain lidocaine and 1 mL of 1:1000 epinephrine. At which of
the following times after infiltration is concentration of lidocaine in the blood expected to be the highest in this
patient?
D. 8–18 hours after surgery.
The safe dosage of lidocaine in liposuction is 35 to 55 mg/kg. Peak lidocaine levels are reported to be 8 to 18
hours after infiltration. Oftentimes, patients are discharged to home when peak levels occur.
1,2,3,4
REFERENCES
1. Klein JA. Tumescent technique for local anesthesia improves safety in large-volume liposuction. Plast Reconstr
Surg 1993;92:1085; discussion 1099
2. Ostad A, Kageyama N, Moy RL. Tumescent anesthesia with a lidocaine dose of 55 mg/kg is safe for liposuction.
Dermatol Surg 1996;22:921
3. Gutowski KA. Tumescent analgesia in plastic surgery. Plast Reconstr Surg 2014;134(4 Suppl 2):50S–57S
4. Swanson E. Prospective study of lidocaine, bupivacaine, and epinephrine levels and blood loss in patients undergoing liposuction and abdominoplasty. Plast Reconstr Surg 2012;130(3):702–722
CLINICAL CONSIDERATIONS
10. Compared with standard suction-assisted liposuction, what is a benefit of laser-assisted techniques?
A. Decreased postoperative ecchymosis.
The answer is A, decreased postoperative ecchymosis, as laser wavelengths can aid in photocoagulation of
small vessels. Laser-assisted liposuction (LAL) is more costly and more time consuming given the addition
of laser energy to the technique. Subdermal tissues are heated, leading to skin tightening but can also lead
to thermal injury.
1
REFERENCE
1. Badin AZ, Gondek LB, Garcia MJ, et al. Analysis of laser lipolysis effects on human tissue samples obtained from
liposuction. Aesthetic Plast Surg 2005;29:281
CLINICAL CONSIDERATIONS
11. A 43-year-old woman is requesting improved abdominal contour. She has had three children and on examina-
tion has lipodystrophy, excessive infraumbilical skin, and a moderate diastasis. Which contouring procedure
would most effectively treat her complaints?
D. Lipoabdominoplasty.
The answer is D, lipoabdominoplasty, which can utilize liposuction to refine body contour after a standard
abdominoplasty. Liposuction techniques alone are not appropriate as the patient has excessive skin, which
will not be treated by liposuction alone. Cryotherapy may offer mild skin tightening and retraction but will
not treat the patient's diastasis.
1,2
REFERENCES
1. Iverson RE, Pao VS. MOC PS (SM) CME article: liposuction. Plast Reconstr Surg 2008;121 (4Suppl):S1
2. Saldanha OR, Azevedo SF, Delboni PS, Saldanha Filho OR, Saldanha CB, Uribe LH. Lipoabdominoplasty: the
Saldanha technique. Clin Plast Surg 2010;37(3):469–481
58. Brachioplasty
Adam Jacoby
See Essentials of Aesthetic Surger y, pp. 818–827
SURGICAL ANATOMY
1. Which structure courses with the medial antebrachial cutaneous nerve, superficial to the deep fascia of the
arm?
A. Basilic vein.
B. Cephalic vein.
C. Median nerve.
D. Medial nerve.
E. Brachial artery.
OPERATIVE SELECTION
2. In a patient with lipodystrophy of the upper arm, with both excess fat and skin extending on to the chest
wall, what is the preferred brachioplasty technique?
A. Cryotherapy.
B. Limited medial brachioplasty.
C. Suction-assisted liposuction (SAL) alone.
D. Ultrasound-assisted liposuction (UAL) alone.
E. Extended brachioplasty with or without liposuction.
SURGICAL COMPLICATIONS
3. What is the most common patient complaint after brachioplasty?
A. Seroma.
B. Hematoma.
C. Numbness.
D. Wound dehiscence.
E. Scar hypertrophy.
SURGICAL TIMING
4. What is the minimum time bet ween bariatric surgery and brachioplasty during which a patient should be
weight stable?
A. 1 month.
B. 3 months.
C. 6 months.
D. 12 months.
E. 18 months.
SURGICAL ANATOMY
5. In a standard brachioplasty, which structure is most at risk for damage?
A. Posterior cord of brachial plexus.
B. Median nerve.
C. Medial antebrachial cutaneous nerve.
D. Thoracic duct.
E. Brachial artery.
Chapter 58&Brachioplasty 437
PREVENTIVE COMPLICATIONS
6. Which of the following should be employed when brachioplasty incisions cross the axilla in order to prevent
contractures?
A. Progressive tension sutures.
B. Z-plasty.
C. V-Y advancement.
D. Drain placement.
E. Barbed suture use.