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458 Part IX&Body Contouring
3. Rosen A. Use of absorbablebarbedsuture and progressive tension techniquein abdominoplasty:a novel approach.
Plast Reconstr Surg 2010;125:1024
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.
Studies demonstrate that flap perfusion is equivalent in lipoabdominoplasty compared to traditional
abdominoplasty if selective undermining principles are followed. An understanding of the blood supply
is key to avoiding abdominoplasty flap compromise. Saldanha et al have shown that by performing limited
undermining centrally they are able to perform more lipoabdominoplasty. However, multiple strategies
exist as long as care is taken to respect the dominant blood supply to the abdominoplasty flap which comes
from Zone III with some minor contribution from Zone I (Fig. 60.5).
1,2,3
Fig. 60.5 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. Saldanha OR, Federico R, Daher PF, et al. Lipoabdominoplasty. Plast Reconstr Surg 2009;124:934
2. Roostaeian J, Harris R, Farkas JP, et al. Comparison of limited-undermining lipoabdominoplasty and traditional
abdominoplasty using laser fluorescence. Aesth Surg Journal 2014;34:741
3. Nahai F. The Art of Aesthetic Surgery: Principles & Techniques. New York: Thieme Publishers; 2005
CLINICAL CONSIDERATIONS
13. A key surgical maneuver for preserving flap perfusion during a lipoabdominoplasty includes which of the
following?
D. Limiting undermining of the abdominal flap to the central area of zone 1 where plication will be
performed.
Lipoabdominoplasty is safe if selective undermining centrally with preservation of perforators along the
lateral aspects of the rectus muscles is performed. Surgical anatomical disruption of the blood supply to the
abdominal wall was first considered and discussed by Nahai et al and elaborated upon by Huger, who
extended these concepts to the specific case of the abdominoplasty flap. After abdominoplasty flap elevation, zone 3 vasculature remains the dominant source of blood supply to the f lap; zone 1, the central abdomen, was rendered relatively underperfused.
1,2,3
Chapter 60&Abdominoplasty 459
REFERENCES
1. Saldanha OR, Federico R, Daher PF, et al. Lipoabdominoplasty. Plast Reconstr Surg 2009;124:934
2. Nahai F, Brown RG, Vasconez LO. Blood supply to the abdominal wall as related to planning abdominal incisions.
Am Surg 1976;42(9):691–695
3. Huger WE Jr. The anatomic rationale for abdominal lipectomy. Am Surg 1979;45(9):612–617
CLINICAL CONSIDERATIONS
14. Which of the following is true in patients undergoing a mini-abdominoplasty in which the umbilicus is
transected?
C. The umbilicus can be expected to move caudal by 2 cm.
The mini-abdominoplasty is indicated in patients with primarily an excess of infraumbilical skin and fat. In
mini-abdominoplasties, the umbilicus remains attachedtothe abdominal flap.If necessary, the umbilical stalk
is transected at the level of the anterior rectus sheath and moved caudally (inferiorly) approximately 2 cm.
1,2
REFERENCES
1. Nahai F. The Art of Aesthetic Surgery: Principles & Techniques. New York: Thieme Publishers; 2005
2. LandfairAS, Rubin JP.Applied anatomy in body contouring. In: Nahai F, ed. The Art of Aesthetic Surgery: Principles
& Techniques. New York: Thieme Publishers; 2005
CLINICAL CONSIDERATIONS
15. In the Lockwood high-lateral-tension abdominoplasty, how does the oblique vector of pull result from?
C. Excising more skin laterally than centrally.
Lockwood high-lateral-tension abdominoplasty is indicated in patients with excess skin infraumbilically
that is primarily vertical in nature and excess skin in the epigastric region that is primarily horizontal
in nature. During the procedure, less skin is taken centrally, and more is resected laterally, resulting in
an oblique vector of pull.
1
REFERENCE
1. Lockwood T. High-lateral-tension abdominoplasty with superficial fascial system suspension. Plast Reconstr Surg
1995;96:603
CLINICAL CONSIDERATIONS
16. In a fleur-de-lis abdominoplasty, maximal vascular supply is maintained by which of the following maneuvers?
E. Leaving the abdominal wall flaps attached to the underlying fascia except in the areas of planned
excision.
The fleur-de-lis abdominoplasty can address both horizontal and vertical excess. However, it is paramount
to leave the skin flaps attached to the underlying fascia, except in areas contained within the fleur-de-lis
excision to maximize vascularity. Liposuction can be performed concurrently.
1
REFERENCE
1. Dellon AL. Fleur-de-lis abdominoplasty. Aesthetic Plast Surg 1985;9:27
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?
B. Reverse abdominoplasty with concurrent mastopexy using inverted-T skin excision pattern.
The reverse abdominoplasty can safely be combined with breast procedures (e.g., a Wise pattern reduction
or mastopexy) as the inframammary fold incision can be used for both the procedures. The unsightly epigastric protrusion occurs when the epigastrium bulges out against a distended lower abdomen. Epigastric
protrusion occurs when plication of the muscle aponeurotic wall of the abdomen brings the epigastrium,
skin, and subcutaneous tissues to the midline. After 3 to 4 months, natural loosening of the tissues may
460 Part IX&Body Contouring
result in accommodation of the epigastrium into an unnatural shape. A revision traditional
abdominoplasty would not be the best technique to address the epigastric fullness and skin excess as this
would require unnecessary undermining from the pubic symphysis to the epigastric area. Liposuction of
this area would not be part of an appropriate surgical treatment plan. Staging of the breast procedure and
reverse abdominoplasty arenotnecessary.
1,2,3
REFERENCES
1. Alderman AK, Collins ED, Steu R, et al. Benchmarking outcomes in plastic surgery: national complication rates for
abdominoplasty and breast augmentation. Plast Reconstr Surg 2009;124:2127
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
3. BaroudiR, Keppke EM, Carvalho CG. Mammary reduction combined with reverse abdominoplasty. Ann Plast Surg
1979;2:368
CLINICAL CONSIDERATIONS
18. Which of the following procedures carries the greatest risk of systemic complications?
A. Abdominoplasty with liposuction of flanks.
Abdominoplasty, especially when combined with other procedures such as liposuction, has a higher systemic complication rate than any other type of routine aesthetic surgical procedure. Systemic complications can include deep vein thrombosis/pulmonary embolism, respiratory compromise, abdominal
compartment syndrome, and systemic infections.
1,2
REFERENCES
1. Alderman AK, Collins ED, Steu R, et al. Benchmarking outcomes in plastic surgery: national complication rates for
abdominoplasty and breast augmentation. Plast Reconstr Surg 2009;124:2127
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
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?
D. Instruct the patient to go to nearest emergency room for evaluation of venous thromboembolism.
Any postoperative patient with shortness of breath needs to be evaluated for venous thromboembolism by
venous duplex ultrasound and/or a dedicated CTPE particularly in regard to the increased potential risk of
venous thromboembolism/pulmonary embolism (VTE/PE) in abdominal based procedures which may be
>4 hours or in patients with a higher medical risk profile.
1,2,3
REFERENCES
1. Spieglman J, Levine RH. abdominoplasty: a comparison of outpatient and inpatient procedures shows that it is a
safeand effectiveprocedureforoutpatientsin an office-basedsurgeryclinic.PlastReconstrSurgery 2006;118:517
2. Stewart KJ, Stewart DA, Coghlan B, et al. Complications of 278 consecutive abdominoplasties. J Plast Reconstr
Aesthet Surg 2006;59:1152
3. Pannucci CJ, MacDonald JK, Ariyan S, et al. Benefits and risks of prophylaxis for deep venous thrombosis and pulmonary embolus in plastic surgery: a systematic review and meta-analysis of controlled trials and consensus conference. Plast Reconstr Surg 2016;137(2):709–730
61. Medial Thigh Lift
Ara A. Salibian
See Essentials of Aesthetic Surger y, pp. 856–868
ANATOMY
1. Which of the following structures can be utilized to anchor tissues during a medial thigh lift?
A. Scarpa's fascia.
B. Colles fascia.
C. Adductor longus tendon.
D. Pubis.
E. Sartorius muscle.
PREOPERATIVE EVALUATION: HISTORY AND PHYSICAL EXAMINATION
2. A 53-year-old female with no significant past medical history presents with complaints of excess fat and skin
redundancy in bilateral thighs. Upon examination, the patient has lipodystrophy and moderate skin laxity
that extends beyond the upper one-third of the thigh. What is the most appropriate surgical plan according
to the classification for non-massive-weight-loss patients?
A. Liposuction alone.
B. Liposuction and a horizontal skin excision only.
C. Liposuction and a vertical skin excision only.
D. Liposuction with a combined horizontal and vertical skin excision.
E. Staged procedure with liposuction first then excisional thigh lift.
TECHNIQUES
3. A patient is undergoing a traditional medial thigh lift with crescentic excision. The surgeon marks a signifi-
cant amount of skin for excision that results in some tension upon closure. What is the most likely postoperative complication in this patient?
A. Hematoma.
B. Labial spreading.
C. Infection.
D. Complete wound dehiscence.
E. Seroma.
TECHNIQUES
4. Which of the following structures is routinely encountered and should be preserved during a medial thigh
lift?
A. Femoral artery.
B. Sciatic nerve.
C. Great saphenous vein.
D. Lesser saphenous vein.
E. Obturator nerve.
TECHNIQUES
5. During a medial thigh lift, the surgeon proceeds in the deep plane in the proximal portion of the excision and
excises significant amount of fat between adductor longus and the sartorius muscle. Which of the following
complications is most likely secondary to this technique?
A. Foot drop.
B. Wound dehiscence.
C. Paresthesias of the lateral leg.
D. Lower extremity lymphedema.
E. Infection.
462 Part IX&Body Contouring
TECHNIQUES
6. A massive-weight-loss patient is undergoing a medial thigh lift with a longitudinal component due to excess
skin laxity in the middle and distal thigh. Which of the following muscle tendons should be used as a refer ence for the initial scar line during preoperative marking?
A. Adductor longus.
B. Adductor magnus.
C. Vastus medialis.
D. Sartorius.
E. Gracilis.
COMPLICATIONS
7. A 50-year-old male patient returns to the office after undergoing a medial thigh lift with a longitudinal inci-
sion complaining of pain and swelling in the right thigh. Examination reveals a large fluid collection in the
mid-medial thigh with an obvious fluid wave and no overlying signs of infection. What is the best first step in
management?
A. Return to the operating room for drainage and excision of seroma wall.
B. Injection of a sclerosing agent.
C. Referral to interventional radiology for closed suction drain placement.
D. Office aspiration and compression with elastic bandage.
E. Compression and administration of oral antibiotics.
Chapter 61&Medial Thigh Lif t 463
Answers
ANATOMY
1. Which of the following structures can be utilized to anchor tissues during a medial thigh lift?
B. Colles fascia.
The Colles fascia is a deep layer of fascia in the thigh that is contiguous with the Scarpa's fascia of the abdominal wall and attaches to the ischiopubic rami of the bony pelvis as well as the posterior border of the urogenital diaphragm. It can be recognized by its yellowish hue. It can be easily identified at the deepest and
most lateral aspect of the vulvar soft tissue. Anchoring sutures should be placed to the Colles fascia in the
groin to minimize labial spread and stabilize the overlying soft tissue envelope. Sutures in muscle or tendon
should be avoided as these can tear through upon patient movement and ambulation.
REFERENCE
1. Mathes DW, Kenkel JM. Current concepts in medial thighplasty. Clin Plast Surg 2008;35:151
PREOPERATIVE EVALUATION: HISTORY AND PHYSICAL EXAMINATION
2. A 53-year-old female with no significant past medical history presents with complaints of excess fat and skin
redundancy in bilateral thighs. Upon examination, the patient has lipodystrophy and moderate skin laxity
that extends beyond the upper one-third of the thigh. What is the most appropriate surgical plan according
to the classification for non-massive-weight-loss patients?
D. Liposuction with a combined horizontal and vertical skin excision.
According to the classification for non-massive-weight-losspatients, a patient with lipodystrophy and moderate skin laxity extending beyond the upper one-third of the thigh is a Type III patient. These patients benefit from both liposuction (due to the lipodystrophy) as well as a vertical component of excision added to the
horizontal excision due to the increased skin laxity more distal in the thigh that will not be addressed by a
crescentic excision only. Patients who are candidates for liposuction alone only have lipodystrophy without
skin laxit y (Type I). Those who are best suited for liposuction and a crescentic horizontal excision only have
lipodystrophy and skin laxity limited to the upper one-third of the thigh (Type II). Finally, patients who have
very severe skin laxity as well as lipodystrophy (Type V) may benefit from a staged procedure (Table 61.1).
1
1
Table 61.1 Classification and Surgical Recommendations for Non-Massive-Weight-Loss Patients
Classification Description Treatment
Type I Lipodystrophy with no sign of skin laxity Liposuction alone
Type II Lipodystrophy and skin laxity confined to the
upper third of the thigh
Type III Lipodystrophy and moderate skin laxity that
extends beyond the upper third of the thigh
Type IV Moderate skin laxity that extends the length
of the thigh
Type V Severe medial thigh skin laxity with
lipodystrophy
Liposuction and a horizontal skin incision in
the medial thigh
Both liposucti on and horizontal and vertical
skin excision in the medial thigh
Longer vertical resection than type III
Staged procedure:
First stage: Aggressive liposuction
Second stage: Excisional medial thigh lift
REFERENCE
1. Mathes DW, Kenkel JM. Current concepts in medial thighplasty. Clin Plast Surg 2008;35:151
464 Part IX&Body Contouring
TECHNIQUES
3. A patient is undergoing a traditional medial thigh lift with crescentic excision. The surgeon marks a signifi-
cant amount of skin for excision that results in some tension upon closure. What is the most likely postoperative complication in this patient?
B. Labial spreading.
Labial spreading is a common complication when crescentic thigh lift patients are marked with excess excision of skin. The vulva do not tolerate much lateral tension and therefore are easily deformed with excess pull
from a tight incision. Patients should be marked while they are in a frog-leg position to allow the surgeon to
determine the safe amount of skin resection to prevent labial distortion when the legs are abducted.
Although wound healing complications are very common with thigh lift procedures and this patient is at
a higher risk of having areas of wound dehiscence secondary to tension at closure, a complete dehiscence
of the entire wound is unlikely.
1,2,3
REFERENCES
1. Lewis JR. Correction of ptosis of the thighs: the thigh lift. Plast Reconstr Surg 1966;37:494
2. Bertheuil N, Thienot S, Huguier V, et al. Medial thighplasty after massive weight loss: are there any risk factors for
postoperative complications? Aesthetic Plast Surg 2013;38:63
3. Gusenoff JA, Coon D, Nayar H, et al. Medial thigh lift in the massive weight loss population: outcomes and com-
plications. Plast Reconstr Surg 2015;135:98
TECHNIQUES
4. Which of the following structures is routinely encountered and should be preserved during a medial thigh lift?
C. Great saphenous vein.
The great saphenous vein is encountered in the subcutaneous tissue of the medial thigh. It runs along the posterior border of the adductor longus and will become more superficial as it travels distally, more easily encountered just posterior to the knee. Dissection should proceed in a plane superficial to the great saphenous vein
and injury to the vein avoided to prevent an increased risk of lymphedema. Although the femoral artery can be
encountered in the femoral triangle, this would indicate a dissection that has proceeded far too deep. The sciatic nerve resides in the posterior thigh and the lesser saphenous vein in the posterior lower leg. The obturator
nerve can also be found in the medial thigh but much deeper, innervating the gracilis muscle.
1,2
REFERENCES
1. Lockwood TE. Maximizing aesthetics in lateral-tension abdominoplasty and body lifts. Clin Plast Surg
2004;31:523
2. Mathes DW, Kenkel JM. Current concepts in medial thighplasty. Clin Plast Surg 2008;35:151
TECHNIQUES
5. During a medial thigh lift, the surgeon proceeds in the deep plane in the proximal portion of the excision and
excises significant amount of fat between adductor longus and the sartorius muscle. Which of the following
complications is most likely secondary to this technique?
D. Lower extremity lymphedema.
The femoral triangle is bound by the adductor longus medially, the sartorius laterally, and the inguinal ligament superiorly. This triangle contains critical structure such as the femoral artery, vein, and nerve, but
always houses important nodal basins and lymphatic channels. Dissection should remain superficial in this
region to avoid disturbing these lymphatic channels, which can subsequently result in debilitating lymphedema of the lower extremity.
1,2,3
REFERENCES
1. Bertheuil N, Thienot S, Huguier V, et al. Medial thighplasty after massive weight loss: are there any risk factors for
postoperative complications? Aesthetic Plast Surg 2013;38:63
2. Gusenoff JA, Coon D, Nayar H, et al. Medial thigh lift in the massive weight loss population: outcomes and com-
plications. Plast Reconstr Surg 2015;135:98
3. Moreno CH, Neto HJ, Junior AH, et al. Thighplasty after bariatric surgery: evaluation of lymphatic drainage in
lower extremities. Obes Surg 2008;18:1160
Chapter 61&Medial Thigh Lif t 465
TECHNIQUES
6. A massive-weight-loss patient is undergoing a medial thigh lift with a longitudinal component due to excess
skin laxity in the middle and distal thigh. Which of the following muscle tendons should be used as a refer ence for the initial scar line during preoperative marking?
A. Adductor longus.
The medial thigh lift in massive-weight-loss patients often incorporates a longitudinal component extending
down the medial leg to address skin laxity of the middle and distal thigh that cannot be corrected with a
traditional crescentic excision. The longitudinal excision is marked by first drawing a line along the adductor
longus tendon down to the knee. The skin is then displaced anteriorly and posteriorly, and points are marked
along the reference line as dictated by the adductor longus tendon. Connecting these points after moving
down the leg will delineate the skin excision that should place the scar in the medial thigh with the appropriate tension. Markings are checked for symmetry and rechecked in the operating room.
1,2
REFERENCES
1. Bertheuil N, Thienot S, Huguier V, et al. Medial thighplasty after massive weight loss: are there any risk factors for
postoperative complications? Aesthetic Plast Surg 2013;38:63
2. Gusenoff JA, Coon D, Nayar H, et al. Medial thigh lift in the massive weight loss population: outcomes and complications. Plast Reconstr Surg 2015;135:98
COMPLICATIONS
7. A 50-year-old male patient returns to the office after undergoing a medial thigh lift with a longitudinal inci-
sion complaining of pain and swelling in the right thigh. Examination reveals a large fluid collection in the
mid-medial thigh with an obvious fluid wave and no overlying signs of infection. What is the best first step in
management?
D. Office aspiration and compression with elastic bandage.
Seromas are relatively common complications in body-contouring procedures with incidences of around 9%
cited after thigh lift in massive weight loss patients. Drains should be left in place until output is usually less
than 20 to 30 cc per day; however, seromas can still form after drain removal. Initially treatment of seromas
involves needle aspiration, which can be done in the office without the use of ultrasound if a palpable collection is present. Compression after aspiration helps minimize potential dead space for fluid accumulation.
Secondary measures for seroma re-accumulation after aspiration include drain placement, use of sclerosing
agents, or operative drainage and excise of the seroma cavity with placement of quilting sutures.
1
REFERENCE
1. Gusenoff JA, Coon D, Nayar H, et al. Medial thigh lift in the massive weight loss population: outcomes and complications. Plast Reconstr Surg 2015;135:98
62. Body Contouring in Massive-Weight-Loss Patients
Adam Jacoby
See Essentials of Aesthetic Surger y, pp. 869–886
PREOPERATIVE CONSIDERATIONS
1. Which of the following bariatric surgery techniques is considered both a restrictive and malabsorptive
procedure?
A. Gastric sleeve.
B. Laparoscopic adjustable gastric band.
C. Weight loss balloon.
D. Roux-en-Y gastric bypass.
E. LINX device.
PREOPERATIVE CONSIDERATIONS
2. After gastric bypass surgery, when should body contouring be performed?
A. When patient's body mass index (BMI) is >45.
B. When the patient's body mass index (BMI) is >40.
C. <3 months after bypass surgery.
D. When patient's weight is fluctuating.
E. After weight stabilization for at least 6 months.
PREOPERATIVE CONSIDERATIONS
3. What is the most common nutritional deficiency after bariatric surgery?
A. Iron deficiency anemia.
B. Rickets.
C. Scurvy.
D. Pellagra.
E. Beriberi.
OPERATIVE SELECTION
4. In a patient with both horizontal and vertical abdominal excess, addition of which of the following surgical
techniques will improve body contour?
A. Progressive tension sutures.
B. Vertical resection (fleur-de-lis).
C. Mons lift.
D. Circumferential body lift.
E. Liposuction.
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 62&Body Contouring in Massive-Weight-Loss Patients 467
PATHOPHYSIOLOGY OF FACIAL AGING
6. What is the cause of premature facial aging in the massive weight loss patient?
A. Relaxation of the facial retaining ligaments.
B. Subcutaneous atrophy.
C. Skin redundancy.
D. SMAS laxity.
E. Osteoporotic bone loss.
POSTSURGICAL COMPLICATIONS
7. Early seroma after body contouring procedures is best treated first with which of the following modalities?
A. Compression.
B. Aspiration.
C. Sclerosing agent.
D. Seroma cavity resection.
E. Drain placement.
POSTSURGICAL COMPLICATIONS
8. Which of the following body contouring procedures is associated with the highest venous thromboembolism
risk?
A. Mastopexy.
B. Medial thigh lift.
C. Abdominoplasty.
D. Rhytidectomy.
E. Brachioplasty.
SURGICAL ANATOMY
9. Suturing of Scarpa's fascia of the thigh to which of the following structures increases longevity of the result
and decreases the risk of hypertrophic scarring?
A. Dartos fascia.
B. Camper's fascia.
C. Colles fascia.
D. Inguinal ligament.
E. Buck's fascia.
PATIENT SELECTION
10. At what body mass index (BMI) is body contouring after massive weight loss considered ideal?
A. <18.
B. 25–30.
C. 35–40.
D. >40.
E. >45.