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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_813_Библиотеки_им_академика_М_И_Перельмана.pdf
448 Part IX&Body Contouring
3. O’Neill RC, Hanson SE, Reece E, Winocour S. Safety considerations of fat grafting in buttock augmentation. Aesthet
Surg J 2021;41(Suppl 1):S25–S30
4. Pat P, Onelio G. Brazilian butt lift–associated mortality: the South Florida experience. Aesthet Surg J 2023;43
(2):162–178
POSTOPERATIVE PERIOD
7. After autologous fat augmentation, a patient experiences confusion, petechiae, fever, and respiratory distress.
How could this complication have been avoided?
E. Keeping the injection cannula parallel to the patient.
The patient in the vignette is experiencing fat embolus syndrome, a life-threatening complication that occurs
when fat enters the bloodstream. The risk is increased when higher volumes of fat are injected, especially
into muscle or near the piriformis due to its proximity to the gluteal vessels. Fat introduced into the inferior
gluteal vein travels through the iliac veins to the inferior vena cava and then the lungs, causing respiratory
distress and the unique clinical syndrome described in the vignette. The risk of fat embolus syndrome can be
reduced by injecting smaller volumes subcutaneously and parallel to the patient. Adequate hydration should
be maintained.
1,2
REFERENCES
1. BrunerTW, Roberts TL, Nguyen K. Complicationsof buttocks augmentation: diagnosis,management,and prevention. Clin Plast Surg 2006;33:449
2. SinnoS, Chang JB, BrownstoneND, et al. Determining the safety and efficacy of gluteal augmentation: a systematic
review of outcomes and complications. Plast Reconstr Surg 2016;137:1151
SILICONE IMPLANT COMPLICATIONS
8. Which of the following complications is most likely following silicone implant augmentation?
A. Wound dehiscence.
Silicone implant augmentation has an overall complication rate of 20 to 40%. Of the complications listed,
wound dehiscence is the most likely (10%). In descending order of incidence, the other complications are
seroma (5%), infection (2%), and paresthesias (1%). Implant exposure, capsular contracture, and chronic pain
may also occur.
1,2,3
REFERENCES
1. Mofid MM, Gonzalez R, de la Peña JA, Mendieta CG, et al. Buttock augmentation with silicone implants: a multicenter survey review of 2226 patients. Plast Reconstr Surg 2013;131:897
2. BrunerTW, Roberts TL, Nguyen K. Complicationsof buttocks augmentation: diagnosis,management,and prevention. Clin Plast Surg 2006;33:449
3. SinnoS, Chang JB, BrownstoneND, et al. Determining the safety and efficacy of gluteal augmentation: a systematic
review of outcomes and complications. Plast Reconstr Surg 2016;137:1151
60. Abdominoplasty
Juan L. Rendon, Simon Moradian
See Essentials of Aesthetic Surger y, pp. 837–855
PERTINENT ANATOMY
1. Which of the follow can safely be excised in thinning of the abdominal wall flap?
A. The superficial fat.
B. The deep subscarpal fat.
C. Both the superficial and deep subscarpal fat.
D. Thinning of the abdominal wall flap is not recommended.
E. Deep fat should only be removed via liposuction.
PERTINENT ANATOMY
2. Which of the following statements describes the anterior abdominal wall anatomy?
A. The rectus abdominis muscles are enveloped by distinct anterior and posterior rectus sheaths along the
entire muscle length.
B. The rectus abdominis muscles are enveloped by distinct anterior and posterior rectus sheaths above the
arcuate line.
C. The rectus abdominis muscles are enveloped by distinct anterior and posterior rectus sheaths below the
arcuate line.
D. The rectus abdominus muscle does not have a distinct anterior sheath below the arcuate line but does have a
posterior rectus sheath.
E. The rectus abdominis muscles are not enveloped by distinct anterior and posterior rectus sheaths.
PERTINENT ANATOMY
3. Vascular zone I of the abdominal wall is supplied by which of the following?
A. Superior and inferior epigastric vessels.
B. Circumflex iliac and external pudendal vessels.
C. Circumflex iliac and intercostal vessels.
D. Intercostal, subcostal, and lumbar vessels.
E. Inferior epigastric and circumflex iliac vessels.
PERTINENT ANATOMY
4. Leaving a layer of fat over the anterior superior iliac spine helps prevent iatrogenic injury to which of the fol-
lowing structures?
A. Lateral cutaneous branches of T7–12.
B. Anterior cutaneous branches of T7–12.
C. Femoral nerve.
D. Lateral femoral cutaneous nerve.
E. Ilioinguinal nerve.
PERTINENT ANATOMY
5. Characteristics of an aesthetically pleasing umbilicus include which of the following?
A. Superior hooding, inferior retraction, round/ellipsoid shape, shallow.
B. Superior hooding, inferior retraction, tear drop shape, deep.
C. Inferior redundancy, superior retraction, tear drop shape, shallow.
D. Inferior redundancy, superior retraction, round/ellipsoid shape, deep.
E. Inferior redundancy, inferior retraction, tear drop shape, deep.
450 Part IX&Body Contouring
PERTINENT ANATOMY
6. Which of the following structures contributes to the major blood supply of the umbilicus?
A. Superior epigastric artery.
B. Deep inferior epigastric artery.
C. Median umbilical ligament.
D. Ligamentum teres.
E. Subdermal plexus.
CLINICAL CONSIDERATIONS
7. Which of the following is an absolute contraindication to abdominoplasty?
A. BMI >40 kg/m
B. Active smoking status.
C. Body dysmorphic disorder.
D. Previous abdominal surgery with subcostal scar.
E. History of thromboembolic disease.
2
.
CLINICAL CONSIDERATIONS
8. When should the use of sequential compression devices, which are highly recommended for the prevention of
thromboembolic events, be applied/started?
A. Prior to induction.
B. After induction but prior to incision.
C. After incision.
D. Postoperatively.
E. Sequential compression devices are not routinely needed.
CLINICAL CONSIDERATIONS
9. In order to prevent postoperative deformity, the transverse abdominoplasty incision should be placed at least
______ from the top of the vulval commissure.
A. 2 cm.
B. 3 cm.
C. 5 cm.
D. 8 cm.
E. 10 cm.
CLINICAL CONSIDERATIONS
10. After removal of excess skin and subcutaneous fat, “dog-ears” can be minimized by which of the following
maneuvers?
A. Rotating the upper abdominal wall flap laterally.
B. Limiting undermining of the superior abdominoplasty flap.
C. Avoiding lateral extension of the incision.
D. Advancing the upper abdominal wall flap medially.
E. Avoiding liposuction to the flank region.
CLINICAL CONSIDERATIONS
11. The use of progressive tension sutures results in which of the following?
A. Increased rates of seroma and hematoma.
B. Decreased tension on the incision and decreased dead space.
C. Increased tension on the incision and prolonged need for closed suction drains.
D. Decreased tension on the increased and prolonged need for closed suction drains.
E. Decreased overall operative time.
CLINICAL CONSIDERATIONS
12. Which of the following statements is true regarding perfusion to the abdominal wall flap in lipoabdomino-
plasty versus traditional abdominoplasty?
A. Flap perfusion is equivalent in lipoabdominoplasty and traditional abdominoplasty.
B. Flap perf usion is higher in lipoabdominoplasty than in traditional abdominoplasty.
Chapter 60&Abdominoplasty 451
C. Flap perfusion is higher in traditional abdominoplasty than in lipoabdominoplasty.
D. Wide flap undermining and liposuction of the superior abdominoplasty flap are not associated with a
decrease in flap perfusion centrally.
E. The difference in flap perfusion between lipoabdominoplasty and traditional abdominoplasty techniques is
unknown.
CLINICAL CONSIDERATIONS
13. A key surgical maneuver for preserving flap perfusion during a lipoabdominoplasty includes which of the
following?
A. Limiting undermining of the abdominal flap to zones 2 and 3.
B. Limiting undermining of the abdominal flap to zone 2 only.
C. Limiting undermining of the abdominal flap to zone 3 only.
D. Limiting undermining of the abdominal flap to the central area of zone 1 where plication will be per formed.
E. Wide undermining can be performed in all zones without risk of flap perfusion.
CLINICAL CONSIDERATIONS
14. Which of the following is true in patients undergoing a mini-abdominoplasty in which the umbilicus is
transected?
A. The umbilical stalk should never be transected during this procedure.
B. The umbilicus can be expected to move cephalad by 2 cm.
C. The umbilicus can be expected to move caudal by 2 cm.
D. The umbilicus can be expected to move up to 5 cm caudally.
E. The umbilicus should be excised from the abdominal wall flap and the defect repaired primarily.
CLINICAL CONSIDERATIONS
15. In the Lockwood high-lateral-tension abdominoplasty, how does the oblique vector of pull result from?
A. Uniformly excising skin centrally and laterally.
B. Excising more skin centrally than laterally.
C. Excising more skin laterally than centrally.
D. Excising skin only centrally.
E. Minimal central undermining.
CLINICAL CONSIDERATIONS
16. In a fleur-de-lis abdominoplasty, maximal vascular supply is maintained by which of the following maneuvers?
A. Limiting resection of excess skin and fat to the periumbilical region.
B. Addressing only horizontal excess through a vertical incision.
C. Avoidance of any liposuction.
D. Aggressively undermining the abdominal wall flaps to allow for maximal resection of excess skin and fat as
well as maximal mobilization of the flaps centrally.
E. Leaving the abdominal wall flaps attached to the underlying fascia except in the areas of planned excision.
CLINICAL CONSIDERATIONS
17. Which of the following is the best surgical plan for a patient who is seeking correction of her Grade 3 ptosis
in addition to resultant epigastric skin excess and protrusion 1 year after traditional abdominoplasty?
A. Revision traditional abdominoplasty with concurrent mastopexy using inverted-T skin excision pattern.
B. Reverse abdominoplasty with concurrent mastopexy using inverted-T skin excision pattern.
C. Liposuction of the epigastric fullness with concurrent mastopexy.
D. Reverse abdominoplasty first with staged mastopexy using an inverted-T skin excision pattern.
E. Mastopexy first using inverted-T skin excision pattern with staged reverse abdominoplasty.
CLINICAL CONSIDERATIONS
18. Which of the following procedures carries the greatest risk of systemic complications?
A. Abdominoplasty with liposuction of flanks.
B. Liposuction of abdomen and flanks.
C. Abdominoplasty alone.
D. Breast reduction.
E. Facelift with concurrent quad blepharoplasty.
452 Part IX&Body Contouring
CLINICAL CONSIDERATIONS
19. On postoperative day 2 following lipoabdominoplasty, a patient calls the office with persistent abdominal
soreness and new shortness of breath with ambulation. The best course of action includes which of the
following?
A. Provide reassurance and instruct the patient to continue pain medications as prescribed.
B. Instruct the patient to use the incentive spirometer.
C. Provide reassurance and instruct the patient to remain on bedrest until symptoms subside.
D. Instruct the patient to go to nearest emergency room for evaluation of venous thromboembolism.
E. Instruct the patient to go to nearest emergency room for evaluation of recurrent diastasis.
Chapter 60&Abdominoplasty 453
Answers
PERTINENT ANATOMY
1. Which of the follow can safely be excised in thinning of the abdominal wall flap?
C. Both the superficial and deep subscarpal fat.
The blood supply to the abdominal wall was initially described by Nahai and then further expanded on by
Huger in 1979 with a classification system describing three zones of perfusion. The blood supply to the
deeper fat (subscarpal) is distinct from the blood supply to the skin; therefore, it can be more easily excised
when thinning the abdominal wall flap in an abdominoplasty. Conversely, thinning the superficial layer of fat
may lead to vascular compromise of the overlying skin; however, this can be done safely using liposuction.
Thinning of the deep fat can be done by direct lipectomy or via liposuction (Fig. 60.1). Additionally, various
surgeons use a combination of direct lipectomy and liposuction to address the subscarpal and suprascarpal fat for enhanced safety during lipoabdominoplasty.
1,2,3
Fig. 60.1 Huger vascular zones. (Source: Vascularity of the abdominal wall. In: Janis J, ed. Essentials of Aesthetic
Surgery. 1st Edition. New York: Thieme; 2018.)
REFERENCES
1. Huger WE Jr. The anatomic rationale for abdominal lipectomy. Am Surg 1979;45:612
2. Restifo RJ. Sub-Scarpa's lipectomy in abdominoplasty: an analysis of risks and rewards in 723 consecutive
patients. Aesthet Surg J 2019;39(9):966–976
3. Cárdenas-Camarena L, Reyes-Herrera MF, Vargas-Flores E, López-Fabila DA, Robles-Cervantes JA.
Lipoabdominoplasty: what we have implemented and what we have modified over 26 years. Plast Reconstr
Surg Glob Open 2023;11(2):e4805
PERTINENT ANATOMY
2. Which of the following statements describes the anterior abdominal wall anatomy?
B. The rectus abdominis muscles are enveloped by distinct anterior and posterior rectus sheaths above
the arcuate line.
The arcuate line represents a transition point. Above the arcuate line, there are distinct anterior and posterior
rectus sheaths. Below the arcuate line, the internal oblique and transversus abdominus join the external and
internal obliques to form a single anterior rectus sheath with no posterior rectus sheath. The arcuate line is
roughly halfway between the umbilicus and symphysis pubis.
1,2
454 Part IX&Body Contouring
REFERENCES
1. Nahai F. The Art of Aesthetic Surgery: Principles & Techniques. New York: Thieme Publishers; 2005
2. Patronella C. Redefining abdominal anatomy: 10 key elements for restoring form in abdominoplasty. AesthetSurg
J 2015;35:972
PERTINENT ANATOMY
3. Vascular zone I of the abdominal wall is supplied by which of the following?
A. Superior and inferior epigastric vessels.
The vascular supply to the anterior abdominal wall can be divided into three zones. Zone I is between the
lateral borders of the rectus sheath from the costal margin to a horizontal line drawn between the two anterior superior iliac spines (ASISs); this area is supplied primarily by superficial branches of the superior and
inferior epigastr ic systems. Zone II is below the horizontal line between the two ASISs to the pubic and inguinal creases; this area is supplied by the superficial branches of the circumflex iliac and external pudendal
vessels. Zone III is superior to zone II and lateral to zone I; this area is supplied by intercostals, subcostals, and
lumbar vessels (Fig. 60.2).
1
Fig. 60.2 Huger vascular zones. (Source: Vascularity of the abdominal wall. In: Janis J, ed. Essentials of Aesthetic
Surgery. 1st Edition. New York: Thieme; 2018.)
REFERENCE
1. Huger WE Jr. The anatomic rationale for abdominal lipectomy. Am Surg 1979;45:612
PERTINENT ANATOMY
4. Leaving a layer of fat over the anterior superior iliac spine helps prevent iatrogenic injury to which of the
following structures?
D. Lateral femoral cuatenous nerve.
The lateral femoral cutanoues nerve innervates the skin in the lateral aspect of the thigh. To prevent injury, a
layer of fat should be left over the anterior superior iliac spine (ASIS). Injury to this nerve can cause significant pain, numbness, and dysesthesia in the hip and medial thigh (a condition known as meralgia para-
esthetica)(Fig. 60.3).
1,2
Chapter 60&Abdominoplasty 455
Fig. 60.3 Lateral femoral cutaneous nerve. Diagram of the nerve anatomy. (Source: Lateral femoral cutaneous nerve.
In: Janis J, ed. Essentials of Aesthetic Surgery. 1st Edition. New York: Thieme; 2018.)
REFERENCES
1. Patronella C. Redefining abdominal anatomy: 10 key elements for restoring form in abdominoplasty. AesthetSurg
J 2015;35:972
2. Mandal, P, Russe E, Schwaiger K, Wechselberger G, Feigl G. Anatomical analysis of the lateral femoral cutaneous
nerve and its passage beneath the inguinal ligament. Plast Reconstr Surg 2022;149(5):1147–1151
PERTINENT ANATOMY
5. Characteristics of an aesthetically pleasing umbilicus include which of the following?
A. Superior hooding, inferior retraction, round/ellipsoid shape, shallow.
An aesthetically pleasing umbilicus has superior hooding, inferior retraction, a round or ellipsoid shape, and
is shallow.
1,2,3
REFERENCES
1. Rohrich RJ, Sorokin ES, Brown SA, et al. Is the umbilicus truly midline?Clinical and medicolegalimplications.Plast
Reconstr Surg 2003;112:259
2. Nahai F. The Art of Aesthetic Surgery: Principles & Techniques. New York: Thieme Publishers; 2005
3. Hespe GE, Stepien DM, Sherif RD, et al. Umbilicoplasty in Abdominoplasty: Modifications for Improved Aesthetic
Results. Aesthetic Surgery Journal Open Forum 2021;3(3):ojab025
PERTINENT ANATOMY
6. Which of the following structures contributes to the major blood supply of the umbilicus?
B. Deep inferior epigastric artery.
The blood supply to the umbilicus has multiple contributions from the subdermal plexus, the ligamentum
teres, the median umbilical ligament, and the right and left deep inferior epigastric artery. However, the
major blood supply is via the deep inferior epigastric arter y system. The superior epigastric system is not
a contributor to the blood supply of the umbilicus (Fig. 60.4).
1,2,3,4
456 Part IX&Body Contouring
Fig. 60.4 Blood supply to the umbilicus. (Source: Lateral femoral cutaneous nerve. In: Janis J, ed. Essentials of Aesthetic
Surgery. 1st Edition. New York: Thieme; 2018.)
REFERENCES
1. Nahai F. The Art of Aesthetic Surgery: Principles & Techniques. New York: Thieme Publishers; 2005
2. Patronella C. Redefining abdominal anatomy: 10 key elements for restoring form in abdominoplasty. AesthetSurg
J 2015;35:972
3. Hunstad JP, Repta R. Atlas of Abdominoplasty. Philadelphia: Elsevier Health Sciences; 2008
4. Florman LD. Is the umbilicus truly midline? Correspondence and brief communications. Plast Reconstr Surg
2004;113:1089
CLINICAL CONSIDERATIONS
7. Which of the following is an absolute contraindication to abdominoplasty?
C. Body dysmorphic disorder.
Absolute contraindications to abdominoplasty include significant health risks, unrealistic surgical goals, and
body dysmorphic disorder. Relative contraindications include: comorbid conditions (e.g., heart disease, diabetes, morbid obesity [BMI >40], cigarette smoking), plans for future pregnancy, a history of thromboembolic disease, and subcostal scars.
1,2
REFERENCES
1. Nahai F. The Art of Aesthetic Surgery: Principles & Techniques. New York: Thieme Publishers; 2005
2. Winocour J, Gupta V, Ramirez JR, et al. Abdominoplasty: risk factors, complication rates, and safety of combined
procedures. Plast Reconstr Surg 2015;136:597e
CLINICAL CONSIDERATIONS
8. When should the use of sequential compression devices, which are highly recommended for the prevention of
thromboembolic events, be applied/started?
A. Prior to induction.
For maximal benefit, sequential compression device (SCD) must be applied and started prior to induction of
anesthesia. The mechanism of action of SCDs has been studied. The sequential application of external compression on the lower extremity is believed to increase pulsatile venous flow. This leads to improved emptying of the veins, thereby decreasing venous pressure resulting in an increase in arteriovenous pressure
gradient and subsequent increase in arterial flow. The mechanical forces applied by the SCDs lead to shear
and strain forces on the endothelial cells. This leads to enhanced antithrombotic, profibrinolytic, and
vasodilatory effects, including the release of tissue plasminogen activator (tPA). The increase in tPA is
believed to result from a decrease in tissue plasminogen activator inhibitor 1 (tPAI-1).
1,2,3,4,5
Chapter 60&Abdominoplasty 457
REFERENCES
1. Gordon RJ, Lombard FW. Perioperative venous thromboembolism: a review. Anesth Analg 2017;125(2):403–412
2. Iorio ML, Venturi ML, Davison SP. Practical guidelines for venous thromboembolism chemoprophylaxis in elective
plastic surgery. Plast Reconstr Surg 2015;135(2):413–423
3. Chouhan VD, Comerota AJ, Sun L, Harada R, Gaughan JP, Rao AK. Inhibition of tissue factor pathway during intermittent pneumatic compression: a possible mechanism for antithrombotic effect. Arterioscler Thromb Vasc Biol
1999;19(11):2812–2817
4. Stewart KJ, Stewart DA, Coghlan B, et al. Complications of 278 consecutive abdominoplasties. J Plast Reconstr
Aesthet Surg 2006;59:1152
5. Winocour J, Gupta V, Ramirez JR, et al. Abdominoplasty: risk factors, complication rates, and safety of combined
procedures. Plast Reconstr Surg 2015;136:597e
CLINICAL CONSIDERATIONS
9. In order to prevent postoperative deformity, the transverse abdominoplasty incision should be placed at least
______ from the top of the vulval commissure.
C. 5 cm.
Preoperative markings begin with identification of the pubic bone and the anterior superior iliac crest. The
planned incision should be marked transversely at the level of the pubic bone. At least 5 cm must be left
between this incision and the top of the vulval commissure to prevent postoperative deformity. The planned
incision should extend laterally below the anterior superior iliac spine (ASIS). If possible, keep the incisions
low in order to prevent visibility of the scar.
1,2
REFERENCES
1. LandfairAS, Rubin JP.Applied anatomy in body contouring. In: Nahai F, ed. The Art of Aesthetic Surgery: Principles
& Techniques. New York: Thieme Publishers; 2005
2. Nahai F. The Art of Aesthetic Surgery: Principles & Techniques. New York: Thieme Publishers; 2005
CLINICAL CONSIDERATIONS
10. After removal of excess skin and subcutaneous fat, “dog-ears” can be minimized by which of the following
maneuvers?
D. Advancing the upper abdominal wall flap medially.
In order to avoid or correct “dog-ears,” the abdominal wall flap should be advanced medially and if necessary, the incision should be extended laterally.
1,2
REFERENCES
1. LandfairAS, Rubin JP.Applied anatomy in body contouring. In: Nahai F, ed. The Art of Aesthetic Surgery: Principles
& Techniques. New York: Thieme Publishers; 2005
2. Nahai F. The Art of Aesthetic Surgery: Principles & Techniques. New York: Thieme Publishers; 2005
CLINICAL CONSIDERATIONS
11. The use of progressive tension sutures results in which of the following?
B. Decreased tension on the incision and decreased dead space.
The use of progressive tension sutures helps advance the abdominal wall f lap onto the musculofascia,
which in turn results in progressive tension to be exerted on each suture and away from the incision.
Ultimately, progressive tension sutures help decrease tension on the incision and close dead space to prevent skin necrosis, hypertrophic scaring, hematoma, and seroma formation. Additionally, placement of progressive tension sutures will increase operative time, although not usually to a significant degree.
1,2,3
REFERENCES
1. Pollock H, Pollock T. Progressive tension sutures: a technique to reduce local complications in abdominoplasty.
Plast Reconstr Surg 2000;105:2583
2. Pollock T, Pollock H. Progressive tension sutures in abdominoplasty: a review of 597 consecutive cases. Aesthet
Surg J 2012;32:729