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438 Part IX&Body Contouring
Answers
SURGICAL ANATOMY
1. Which structure courses with the medial antebrachial cutaneous nerve, superficial to the deep fascia of the
arm?
A. Basilic vein.
The answer is A, basilic vein, which pierces the deep fascia of the upper arm about 14 centimeters proximal
to the medial epicondyle. The cephalic vein is more radial, and the median nerve/brachial artery are deeper
structures, not at risk during a brachioplasty (Fig. 58.1).
1,2
Biceps
muscle
Radial
nerve
Triceps
muscle
Biceps
Medial
cubital
sulcus
Medial
epicondyle
Horizontal
excess
Tri ce ps
brachii
muscle
ab
brachii
muscle
Brachial
groove
Posterior
axillary
fold
Ver tica l
excess
Anterior
axillary
fold
Brachial artery
Medial nerve
Basilic vein
Medial antebrachial
cutaneous nerve
Ulnar nerve
Humerus
Fig. 58.1 Anatomy of the arm. (a) External landmarks. (b) Cross section. (Source: Anatomy. In: Janis J, ed. Essentials
of Aesthetic Surgery. 1st Edition. New York: Thieme; 2018.)
REFERENCES
1. CannistraC, ValeroR, Benelli C, et al. Brachioplastyafter massiveweight loss: a simple algorithm for surgical plane.
Aesthetic Plast Surg 2007;31:6
2. Knoetgen J III, Morgan SL. Long-term outcomes and complications associatedwith brachioplasty: as retrospective
review and cadaveric study. Plast Reconstr Surg 2006;117:2219
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?
E. Extended brachioplasty with or without liposuction.
The answer is E, extended brachioplasty with or without liposuction. Limited resection techniques will not
address the excess skin and subcutaneous tissue on the chest wall. Liposuction techniques alone will not
address the excessive skin, which will need to be resected for an excellent result. Extended brachioplasty
with extension onto the chest wall with a Z-plasty in the axilla will provide excellent contour and minimize
axillary webbing or contracture. Cryotherapy may offer mild skin tightening and retraction but will not treat
the level of excess skin and fat described in the above vignette.
1,2,3,4
REFERENCES
1. Appelt EA, Janis JE, Rohrich RJ. An algorithmic approach to upper arm contouring. Plast Reconstr Surg
2006;118:237
Chapter 58&Brachioplasty 439
2. Baroudi R. Body sculpturing. Clin Plast Surg 1984;11:419
3. Gusenoff JA, Coon D, Rubin JP. Brachioplasty and concomitant procedures after massive weight loss: a statistical
analysis from a prospective registry. Plast Reconstr Surg 2008;122:595
4. CannistraC, ValeroR, Benelli C, et al. Brachioplastyafter massiveweight loss: a simple algorithm for surgical plane.
Aesthetic Plast Surg 2007;31:6
SURGICAL COMPLICATIONS
3. What is the most common patient complaint after brachioplasty?
E. Scar hypertrophy.
The answer is D, scar hypertrophy. The other answers are possible adverse outcomes after brachioplasty but
close to 10% of postoperative patients will require a scar revision. Patient counseling and preoperative discussion of scar placement are an important part of the consent process.
1,2,3
REFERENCES
1. Samra S, Sawh-Martinez R, Liu YJ, et al. Optimal placement of brachioplasty scar: a survey evaluation. Plast
Reconstr Surg 2010;126:77
2. Abramson DL. Minibrachioplasty: minimizing scars while maximizing results. Plast Reconstr Surg 2004;114:1631
3. Zomerlei TA, Neman KC, Armstrong SD, et al. Brachioplasty outcomes: a review of a multi practice cohort. Plast
Reconstr Surg 2013;131:883
SURGICAL TIMING
4. What is the minimum time between bariatric surgery and brachioplasty during which a patient should be
weight stable?
C. 6 months.
The answer is C, 6 months between bariatric surgery and brachioplasty. This allows for homeostasis of
tissues and sufficient time to ensure weight stability. Fluctuations in weight place patients at a higher risk
for wound healing issues. Options A and B are too short to determine weight stability.
1,2,3
REFERENCES
1. Aly AS, ed. Body Contouring After Massive Weight Loss. New York: Thieme Publishers; 2006
2. Gusenoff JA, Coon D, Rubin JP. Brachioplasty and concomitant procedures after massive weight loss: a statistical
analysis from a prospective registry. Plast Reconstr Surg 2008;122:595
3. CannistraC, ValeroR, Benelli C, et al. Brachioplastyafter massiveweight loss: a simple algorithm for surgical plane.
Aesthetic Plast Surg 2007;31:6
SURGICAL ANATOMY
5. In a standard brachioplasty, which structure is most at risk for damage?
C. Medial antebrachial cutaneous nerve.
The answer is C, medial antebrachial cutaneous nerve, which arises from the medial cord of the brachial
plexus, which is the most common neurovascular structure damaged during brachioplasty. Liposuction prior
to resection preserve neurovascular structures and facilitates easy resection of subcutaneous tissues. The
structures in all other answer choices are much deeper and should not be encountered during a brachioplasty
(Fig. 58.2).
1,2
440 Part IX&Body Contouring
Biceps
muscle
Radial
nerve
Triceps
muscle
Medial
cubital
sulcus
Medial
epicondyle
Horizontal
excess
Tri ce ps
brachii
muscle
Biceps
brachii
muscle
Brachial
groove
Posterior
axillary
fold
Ver tica l
excess
Anterior
axillary
fold
Brachial artery
Medial nerve
Basilic vein
Medial antebrachial
cutaneous nerve
Ulnar nerve
Humerus
ab
Fig. 58.2 Anatomy of the arm. (a) External landmarks. (b) Cross section. (Source: Anatomy. In: Janis J, ed. Essentials
of Aesthetic Surgery. 1st Edition. New York: Thieme; 2018.)
REFERENCES
1. CannistraC, ValeroR, Benelli C, et al. Brachioplastyafter massiveweight loss: a simple algorithm for surgical plane.
Aesthetic Plast Surg 2007;31:6
2. Knoetgen J III, Morgan SL. Long-term outcomes and complications associatedwith brachioplasty: as retrospective
review and cadaveric study. Plast Reconstr Surg 2006;117:2219
PREVENTIVE COMPLICATIONS
6. Which of the following should be employed when brachioplasty incisions cross the axilla in order to prevent
contractures?
B. Z-plasty.
The answer is B, Z-plasty, which helps prevent contracture in the axilla. Progressive tension sutures can
relieve tension on an abdominoplasty closure and are not useful in brachioplasty. Drains are often placed
during brachioplasty regardless of scar position. Barbed sutures are often used in body contouring procedures to aid in efficiency but often pose problems during brachioplasty as medial arm skin is thin, interfering with wound healing, potentially leading to spitting suture (Fig. 58.3).
1,2,3
Chapter 58&Brachioplasty 441
Fig. 58.3 Brachioplasty marked with vertical cross-hatches. Note the Z-plasty used to prevent contracture across
the axilla.
2018.)
(Source: Operative Procedure. In: Janis J, ed. Essentials of Aesthetic Surgery. 1st Edition. New York: Thieme;
REFERENCES
1. Lockwood T. Brachioplasty with superficial fascial system suspension. Plast Reconstr Surg 1995;96:912
2. Samra S, Sawh-Martinez R, Liu YJ, et al. Optimal placement of brachioplasty scar: a survey evaluation. Plast
Reconstr Surg 2010;126:77
3. ShermakMA, MallalieuJ, Chang D. Barbed suture impact on wound closure in body contouring.PlastReconstrSurg
2010;126:1735
59. Buttock Augmentation
Sammy Sinno, Michael E. Nissan
See Essentials of Aesthetic Surger y, pp. 828–836
INDICATIONS
1. Which of the following patients is the best candidate for gluteal augmentation via autologous fat grafting?
A. A thin patient.
B. A slightly overweight patient.
C. A severely obese patient.
D. A massive weight loss patient.
E. A pregnant patient.
ANATOMY
2. The gluteus maximus muscle originates at the _______ and inserts onto the _______.
A. Medial border of the sacrum; greater trochanter of the femur.
B. Lateral border of the sacrum; lesser trochanter of the femur.
C. Posterior superior iliac spine; midshaft of the femur.
D. Posterior superior iliac spine; greater trochanter of the femur.
E. Lateral border of the sacrum; greater trochanter of the femur.
AESTHETIC ZONES
3. Which of the following is the significance of zone 1 of the 10 gluteal aesthetic zones?
A. For autologous fat grafting, zone 1 is targeted for lipoharvest and creates a desirable contour.
B. Zone 1 is located along the inner gluteal region and should be avoided.
C. Zone 1 is located lateral to midline and should be harvested for fat.
D. Zone 1 is located lateral to midline and should be augmented with fat.
E. Due to high density of nerves and vasculature, zone 1 should be avoided both during lipoharvest and
augmentation.
LIPOHARVEST
4. Most fat in the buttock is removed from which of the following zones?
A. Zones 1–4.
B. Zones 5 and 6.
C. Zones 3 and 5.
D. Zones 5 and 6.
E. Zone 10.
SILICONE IMPLANTS
5. A patient who underwent silicone implant gluteal augmentation is experiencing unilateral shooting pain
down the leg. The implant will most likely be located in which of the following tissue planes?
A. Subcutaneous.
B. Submuscular.
C. Intramuscular.
D. Subfascial.
E. Dual plane with partial subcutaneous and subfascial placement.
Chapter 59&Buttock Augmentation 443
COMPLICATIONS
6. Which of the following methods of augmentation has the lowest rate of complications in regard to
morbidity?
A. Autologous fat grafting.
B. Silicone implants.
C. Saline implants.
D. Autologous fat grafting with implant placement.
E. Autologous flap augmentation.
POSTOPERATIVE PERIOD
7. After autologous fat augmentation, a patient experiences confusion, petechiae, fever, and respiratory distress.
How could this complication have been avoided?
A. Injecting into muscle.
B. Injecting near the piriformis.
C. Injecting higher volumes of fat.
D. Keeping the injection cannula perpendicular to the patient.
E. Keeping the injection cannula parallel to the patient
SILICONE IMPLANT COMPLICATIONS
8. Which of the following complications is most likely following silicone implant augmentation?
A. Wound dehiscence.
B. Capsular contracture.
C. Seroma.
D. Infection.
E. Paresthesias.
444 Part IX&Body Contouring
Answers
INDICATIONS
1. Which of the following patients is the best candidate for gluteal augmentation via autologous fat grafting?
B. A slightly overweight patient.
Slightly overweight patients—especially those with excess sacral, lower back, and posterior triangle fat—are
excellent candidates for gluteal augmentation via autologous fat grafting. These patients typically have
enough excess fat to produce a dramatic aesthetic result while not requiring additional liposuction like
heavier patients would. Pregnancy is a contraindication for gluteal augmentation. Neoplasm or any other
severe comorbid condition is also a contraindication.
REFERENCES
1. TardifM, de la Peña JA. Gluteal augmentation.In: Aston SJ, SteinbrechDS, Walden JL, eds. Aesthetic Plastic Surgery.
Philadelphia: Saunders Elsevier; 2009
2. Cádenas-Camarena L, Arenas-Quintana R, Robles-Cervantes JA. Buttocks fat grafting: 14 years of evolution and
experience. Plast Reconstr Surg 2011;128:545
3. Centeno RF, Young VL. Clinical anatomy in aesthetic gluteal body contouring surgery. Clin Plast Surg 2006;33:347
ANATOMY
2. The gluteus maximus muscle originates at the _______ and inserts onto the _______.
D. Posterior superior iliac spine; greater trochanter of the femur.
The gluteus maximus muscle originates along the lateral sacrum and the posterior iliacspine.It inserts into the
iliotibial tract and the greater trochanter of the femur. It is the main extensor muscle of the hip and the most
superficial of the gluteal muscles, responsible for the bulk and contour of the buttock region (Fig. 59.1).
1,2,3
1
Midreference line
or midgluteal line
Fat
Gluteal
muscles
Ideal
diamond
space
Fig. 59.1 Gluteus maximus muscle anatomy. (Source: Summary of key anatomic and aesthetic concepts. In: Aly A, ed.
Body Contouring: After Massive Weight Loss. 1st Edition. New York: Thieme; 2006.)
Pelvis
REFERENCE
1. Centeno RF, Young VL. Clinical anatomy in aesthetic gluteal body contouring surgery. Clin Plast Surg 2006;33:347
Chapter 59&Buttock Augmentation 445
AESTHETIC ZONES
3. Which of the following is the significance of zone 1 of the 10 gluteal aesthetic zones?
A. For autologous fat grafting, zone 1 is targeted for lipoharvest and creates a desirable contour.
For gluteal augmentation with autologous fat grafting, 10 zones have been defined to guide lipoharvest and
augmentation (Fig. 59.2).
of the intergluteal fold and the posterior iliac dimples. This zone is ideal for lipoharvest, as it creates a
desirable contour after liposuction. Zone 7 is actually the inner gluteal area and is safe to lipoharvest
from.
1,2,3,4,5
Zone 1, also known as the “presacral V,” is defined by the superior point
10
4
2
1
6
7
9
Upper back
Lower back
Flank
Sacrum
3
Upper back
Gluteus
8
Midlateral buttock point C
Diamond zone: inner gluteal/leg injection
5
Outer leg
Inferior gluteal/posterior leg junction
Fig. 59.2 Mendieta's 10 aesthetic units or zones. (1, Sacrum; 2, flank; 3, upper back; 4, lower back; 5, outer leg;
6, gluteus; 7, diamond zone: inner gluteal/leg injection; 8, midlateral buttock point C; 9, inferior gluteal/posterior leg junction; 10, upper back.)
Surgery. 1st Edition. New York: Thieme; 2018.)
(Source: Autologous fat grafting (Mendieta). In: Janis J, ed. Essentials of Aesthetic
REFERENCES
1. Mendieta CG. Classification system for gluteal evaluation. Clin Plast Surg 2006;33:333
2. Mendieta CG. Gluteal reshaping. Aesthet Surg J 2007;27:641
3. Mendieta CG. Gluteoplasty. Aesthet Surg J 2003;23:441
4. Nahai F. The Art of Aesthetic Surgery: Principles & Techniques. New York: Thieme Publishers; 2005
5. Peren PA, Gomez JB, Guerrerosantos J, et al. Gluteus augmentation with fat grafting. Aesthetic Plast Surg
2000;24:412
LIPOHARVEST
4. Most fat in the buttock is removed from which of the following zones?
A. Zones 1–4.
Most fat in the buttock is harvested from zones 1 to 4: sacrum, flank, upper buttock, and lower back. These
regions are located superior to the gluteus muscle, often contain excess fat, and form a pleasing aesthetic
contour after liposuction. Fat is harvested through a 5-millimeter cannula in the deep layers and a 4-millimeter cannula in the superficial layers (Fig. 59.3).
1,2,3
446 Part IX&Body Contouring
10
4
2
1
6
7
9
Upper back
Lower back
Flank
Sacrum
3
Upper back
Gluteus
8
Midlateral buttock point C
Diamond zone: inner gluteal/leg injection
5
Outer leg
Inferior gluteal/posterior leg junction
Fig. 59.3 Mendieta's 10 aesthetic units or zones. (1, Sacrum; 2, flank; 3, upper back; 4, lower back; 5, outer leg;
6, gluteus; 7, diamond zone: inner gluteal/leg injection; 8, midlateral buttock point C; 9, inferior gluteal/posterior leg junction; 10, upper back.)
Surgery. 1st Edition. New York: Thieme; 2018.)
(Source: Autologous fat grafting (Mendieta). In: Janis J, ed. Essentials of Aesthetic
REFERENCES
1. Mendieta CG. Classification system for gluteal evaluation. Clin Plast Surg 2006;33:333
2. Nahai F. The Art of Aesthetic Surgery: Principles & Techniques. New York: Thieme Publishers; 2005
3. Peren PA, Gomez JB, Guerrerosantos J, et al. Gluteus augmentation with fat grafting. Aesthetic Plast Surg
2000;24:412
SILICONE IMPLANTS
5. A patient who underwent silicone implant gluteal augmentation is experiencing unilateral shooting pain
down the leg. The implant will most likely be located in which of the following tissue planes?
B. Submuscular.
The patient in the vignette with unilateral, shooting leg pain in the context of silicone implant gluteal augmentation is likely experiencing symptoms related to compression of the sciatic nerve. There are four possible tissue planes for placement of a gluteal silicone implant: subcutaneous, submuscular, intramuscular,
and subfascial (Fig. 59.4).
injury due to its proximity to the nerve relative to the other tissue locations. To avoid this complication,
the intramuscular approach (option B) is most often used in the United States. However, the dissection is
more difficult, and a seroma is more likely to form.
1,2
The submuscular approach (option A) is the most likely to cause sciatic nerve
Chapter 59&Buttock Augmentation 447
abc
Fig. 59.4 Common locations for silicone implant placement for gluteal augmentation: (a) submuscular,
(b) intramuscular, and (c) subfascial. (Source: Mendieta CG. The Art of Gluteal Sculpting. New York: Thieme
Publishers, 2011.)
REFERENCES
1. Robles JM, TagliapietraJC, Grandi MA. Gluteoplastia de augmento: implante submuscular. Cirplast Ibero Latinoam
1984;10:365
2. Serra F, Aboudib JH, Marques RG. Intramuscular technique for gluteal augmentation: determination and quantification of muscle atrophy and implant position by computed tomographic scan. Plast Reconstr Surg
2013;131:253e
COMPLICATIONS
6. Which of the following methods of augmentation has the lowest rate of complications in regard to
morbidity?
A. Autologous fat grafting.
Complications that may occur after gluteal augmentation include infection, sciatica, seroma, fat resorption,
oil cysts, and wound healing problems. With an overall complication rate of approximately 8%, autologous
fat grafting has a lower rate of complications than other augmentation methods such as silicone implants,
which are associated with a 20 to 40% complication rate. Additionally, combining methods will inherently
always be associated with a slightly higher complication rate. When discussing mortality, according to the
ASERF Task Force calculations for gluteal fat grafting, the risk of pulmonary fat emboli was 1 in 1030
(<0.08%), with a mortality risk of 1 in 3448 (0.03%). It should be noted that various centers in the South
Florida area were found to have a significantlyhigher rate of mortality; however, this was ultimately
attributed to the working environment, and short surgical times.
1,2,3,4
REFERENCES
1. BrunerTW, Roberts TL, Nguyen K. Complicationsof buttocks augmentation: diagnosis,management,and prevention. Clin Plast Surg 2006;33:449
2. Sinno S, Chang JB, Brownstone ND, et al. Determiningthe safety and efficacy of glutealaugmentation:a systematic
review of outcomes and complications. Plast Reconstr Surg 2016;137:1151